Acknowledgment of Notice of Privacy Practices

Form revised 03/2023

I was given the opportunity to read, have read, or had explained to me Vision Advancement Center, PLLC and Advanced Vision Therapy, PLLC’s Notice of Privacy Practice prior to any services offered

The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible

My vision plan requests that all diagnoses related to any medical condition I may have be released to them. As a non-traditional disclosure, release of this information requires my specific authorization:

I authorize the release of medical information to my vision plan

I do not authorize release of medical information to my vision plan

Our office may use standard email to communicate with you. Standard email is not secure and does not guarantee privacy.

I authorize the use of standard email, in spite of the known risks involved, to communicate with me

I do not authorize the use of standard email to communicate with me

Patient First Name

Patient Last Name

Patient Signature

Date

Relationship to patient:

Representative's full name

Representative Signature

Date