Acknowledgement of Privacy Policy and Practices

Consent
I understand that in an attempt to protect the privacy of my identifiable health information, Edgewater Eyecare, LLC has established a Privacy Policy and guidelines for Privacy Practices within their office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purpose of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the Notice of Privacy Practices of Edgewater Eyecare, LLC has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge. By signing below, I understand and acknowledge the Notice of Privacy Practices of Edgewater Eyecare, LLC.
I agree to the privacy policy.
Patient Name*
Date*
MM slash DD slash YYYY
Signature (or patient’s representative)*
I understand that the Practice may wish to contact me for purposes related to my treatment such as to remind me of appointments, leave messages, or to discuss financial/billing business, or to indicate other necessary contacts.
Please Select One*
- Yes, I authorize the Practice to contact me at the contacts (phone #s/email) I have provided. I understand and authorize the practice to leave me a voicemail message if I am unavailable.
- No. I do not agree to these contacts. Do not leave a message.
The following people may have access to my personal health information:
Name Relationship

Name	Relationship