ACKNOWLEDGEMENT

OF NOTICE OF PRIVACY PRACTICES

Read the Notice of Privacy Practices Here

The law requires that EAGLE RANCH VISION SOURCE make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

(Please check one of the following:)

I have read or had explained to me EAGLE RANCH VISION SOURCE's Notice of Privacy Practice and agree to continue my care with EAGLE RANCH VISION SOURCE

I was given the opportunity to read EAGLE RANCH VISION SOURCE's Notice of Privacy Practices, and declined, but wish to continue my care with EAGLE RANCH VISION SOURCE under the terms of EAGLE RANCH VISION SOURCE's privacy policies.

I have read or had explained to me EAGLE RANCH VISION SOURCE's Notice of Privacy Practice and do not wish to continue my care with EAGLE RANCH VISION SOURCE under said terms.

The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as:

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY AND OF SOUND MIND..

Electronic Signature (type your name) Patient Date

 

If you are signing as a personal representative of the patient, please indicate your relationship:

Representative
Relationship to Patient

Read the Notice of Privacy Practices Here