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HIPAA Acknowledgement Form

Acknowledgment of Notice of Privacy Practices

The law requires that Jonathan D. Sher, OD PC makes every effort to inform you of your rights related to your personal health information.
By my signing below, I acknowledge that(Required)
Our office may use standard email and text messaging to communicate with you. Standard email is not secure and does not guarantee privacy.(Required)
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.(Required)
Consent(Required)
Name
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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

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