Skip to main content
Located on 827 East Lamar Blvd in Arlington, TX
Menu


Home » Contact Us » HIPAA Acknowledgment Form

HIPAA Acknowledgment Form

Advanced Vision Care of North Arlington,
PA 827 E. Lamar Blvd. Arlington, TX 76011
817-2754-0655

The law requires that Advanced Vision Care make every effort to inform you of your rights related to your personal health information. by my signing below. I acknowledge that:

Please check off
Please check off
Please check off

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

Patient Name
MM slash DD slash YYYY
Read & Decide