WEA Privacy Practices Choose Your Office*MEDICAL PLAZAPANTHER CREEKACKNOWLEDGEMENT OFNOTICE OF PRIVACY PRACTICES The law requires that Woodlands Eye Associates make every effort to inform you, the patient, of your rights related to your personal health information (PHI). By my signing below, I acknowledge that: Please check only one box below. Yes, I was given the opportunity to read, have read or had explained to me George C. Kaufman, III, ODPA’s Notice of Privacy Practice prior to any services offered. No, I have not read Woodlands Eye Associates’ Notice of Privacy Practices, but, I was given the opportunity to read it upfront and declined but wish to continue my care under the terms of Woodlands Eye Associates’ privacy. The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible. VSP and Superior Vision Plans: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: I authorize the release of medical information to my vision plan I do not authorize the release of medical information to my vision plan I HAVE READ AND UNDERSTAND THIS FORM AND I AM SIGNING IT VOLUNTARILY.Signature*PatientIf you are signing as a personal representative of the patient, please indicate your relationship below.SignatureRepresentativeRelationshipDate* MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
