ANPP

ANPP

ANPP

ANPP

Acknowledgment of Notice of Privacy Practices

The law requires that ReEnvision Eyecare, PLLC make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

I authorize ReEnvision Eyecare, PLLC to release my personal health information to the following individuals:

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:

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

If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor. Please indicate any other parent, step-parent, guardian or other individual(s) authorized to make medical decisions for the minor.

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