HIPAA

  • Patient Acknowledgement and Receipt of Notice of Privacy Practices Pursuant to HIPPA and Consent for Use of Health Information
  • Date Format: MM slash DD slash YYYY
  • The undersigned does hereby acknowledge that he or she has received a copy of this office's Notice of Privacy Practices Pursuant to HIPPA and has been advised that a full copy of this office's HIPPA Compliance Manual is available upon request.

    The undersigned does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Pursuant to HIPPA, the HIPPA compliance Manual, State and Federal Law.
  • List your name
  • Date Format: MM slash DD slash YYYY
  • Signature of Parent/Guardian

Beginning Monday, May 11th, we will be returning to normal business hours and will be seeing patients for all types of vision exams. We are following all COVID-19 guidelines, including sanitizing, wearing face masks and practicing social distancing.