ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

Phone: <a class="ecp-phone-call-phone" href="tel:281-374-4354" style="text-decoration:none"> 281-374-4354
Fax: 281-320-2012
Email: admin@springkleinvision.com (Do not send personal health information by email.)

Name: springkleinECP2016
Address: 6603 FM 2920 Rd, Spring, TX, 77379, US
Telephone: +1 281-374-4354
Price range: $000 - $300

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 that
- I 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 Patient
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNINGIT VOLUNTARILY.
Print Patient's Name
Date
Date Format: MM slash DD slash YYYY
Signature of Patient/Legal Guardian
Relationship to Patient

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