Patient Privacy Notice
Notice to Patient:
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please complete and sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement if you wish.
I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.
Please print your name here
Signature
Email Address
Phone Number
Date
You can print this page with your web browser and either Fax it to us at 913-362-0407 or mail to:
Heart of America Eye Care, P.A.
8901 W. 74th Street, Suite 285
Shawnee Mission, KS 66204