Reynaldo Sitel Test 2

HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Name
First Last
I have been presented with the Notice of Privacy Policy of Dr. Ariel Medina, and have been offered a copy of such policy to keep for my records.
Signature
Date
I hereby acknowledge that I have been provided with a copy of the Policy
Patient initials
Date
I hereby refuse to acknowledge receipt of the Policy. I understand that even though I may refuse to sign this acknowledgment, Provider may still provide treatment to me.
Patient initials
Date
MEDICAL DIGITAL VIDEO AND PHOTO CONSENT
I understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that Dr. Ariel Medina will retain the ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative.
Patient signature
Date
Date Format: MM slash DD slash YYYY

Exam Date
Date Format: MM slash DD slash YYYY
Patient Name
First Last
Sex
- Male
- Female
Birth Date
Address
Street Address City State / Province / Region ZIP / Postal Code
Preferred telephone number
We use phone calls to remind patients of their appointments, we will use the phone number you provide and the call may be live or prerecorded
Secondary telephone number
- Work
- Home
- Cell
Phone
Employer
Occupation
Referred by
Email address
Signature

Dr. Medina's Optical
FRAMES Most frames are warranted against manufacture defects in workmanship for a period of one year from the date of the purchase. Frames are not covered for breakage or loss. In the event that a frame exchange is required for patient satisfaction, a one-time exchange up to the original purchase price of the frame may be made within the first 7 days of purchase. Fees may apply. The Optical is not responsible for Patient's own frames. PRESCRIPTION LENSES We guarantee that your lenses will be made and inspected to the specification of the prescription given. COATINGS Anti-Reflective coating and scratch coating are warranted at no cost to you for a period of one or two years from the date of the purchase. This warranty does not cover loss, theft, or hairline scratches which have not effect on vision. Dispensing fees will apply with replacement of lenses. NON-ADAPT POLICY Lenses are custom made for you, they are non-refundable. It is our policy to remake your lenses one time only at no cost to you if the original prescription is in error or if the patient is non-adapt to a progressive lens. For non-adapt progressive lenses, we will make new lenses in any other design that you wish at no charge within 90 days of dispensing. Original lenses are a custom prescription item which must be discarded. No refunds are issued if the difference in cost or the remake pair is of lesser value. Our lens treatments are the most durable surface protection available. However, any lens can scratch or break. Please follow recommended procedures for care and cleaning. CANCELLATION POLICY Patient has 24 hours to cancel the order. See sales associate for details. OUTSIDE DOCTOR'S CHANGE One Doctor's change will be honored for a period of 30 days from the date of dispense. Costs associated other than prescription will be responsibility of the patient.
Patient name
First Last
Date
Signature

Reynaldo Sitel Test 2

Step 1 of 4

HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

MEDICAL DIGITAL VIDEO AND PHOTO CONSENT

Insurance information

Medical and ocular history

Dr. Medina's Optical