ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES The law requires that Spring Klein Vision Center make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge thatI have read or had explained to me Spring Klein Vision Center's Notice of Privacy Practices and agree to continue my care with Spring Klein Vision Center under said terms.I have read or had explained to me Spring Klein Vision Center's Notice of Privacy Practices and do not wish to continue my care with Spring Klein Vision Center under said terms.The Notice of Privacy Practices could not be read due to the emergent nature of the care of other reason described as:I hereby authorize Spring Klein Vision Center to release the following information contained in my medical record: Contact Lens Prescription & Spectacle Prescription Most Recent Examination Record Billing Information The Complete Record I prefer the above information to be shared as requested with the following person(s):Relationship to PatientI HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNINGIT VOLUNTARILY.Print Patient's NameDate Date Format: MM slash DD slash YYYY Signature of Patient/Legal GuardianRelationship to Patient