The law requires that Las Colinas Vision Center make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

I have read or had explained to me Las Colinas Vision Center’s Notice of Privacy Practice and agree to continue my care with Las Colinas Vision Center under said terms.

I was given the opportunity to read Las Colinas Vision Center’s Notice of Privacy Practices and declined but wish to continue my care with 1st Eye Care under the terms of Las Colinas Vision Center’s privacy policies.

I have read or had explained to me Las Colinas Vision Center’s Notice of Privacy Practice and do not wish to continue my care with Las Colinas Vision Center under said terms.

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

____________________________________________________________________________________________

____________________________________________________________________________________________

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

_________________________________ | ________________ Patient Signature | Date

_________________________________ Printed Name

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

___________________________ | _____________________ Representative | Relationship to Patient