HIPAA PRIVACY ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES Name* First Last Phone I, (the “Patient” or “Patient’s legal representative”) have been presented with the Notice of Privacy Policy (the “Policy”) of Contact Lens and Vision (“the Provider”), and have been offered a copy of such policy to keep for my records. I hereby acknowledge that I have been provided with a copy of the Policy. I hereby refuse to acknowledge receipt of the Policy. I understand that even though I may refuse to sign this acknowledgement, Provider may still provide treatment to me.Signature of Patient or Patient’s legal representative*This field is hidden when viewing the formDate MM slash DD slash YYYY Δ
