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) I was given the opportunity to read, have read or had explained to me Jonathan D. Sher, OD PC'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. Our office may use standard email and text messaging to communicate with you. Standard email is not secure and does not guarantee privacy.(Required) I authorize the release of medical information to my vision plan. I do not authorize release of medical information to my vision plan. 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) I authorize the use of standard email and text messaging, in spite of the known risk involved, to communicate with me. I do not authorize the use of standard email or text messaging to communicate with me. Consent(Required) I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.(Required)Name First Last SignatureHiddenDate MM slash DD slash YYYY 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 Representative's SignatureRelationship to Patient
