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 I have read or had explained to me prior to any services offered Advanced Vision Care Notice of Privacy Practice and agree to continue my care with Advanced Vision Care under said terms.Please check off I have read or had explained to me prior to any services offered Advanced Visioncare's Notice of Privacy Practice and do not wish to continue my care with Advanced Vision Care under said terms.Please check off The Notice of Privacy Practice could not be read due to the emergent nature of the care or other reason described as:I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. Patient Name First Last Date MM slash DD slash YYYY Read & Decide By making a check mark or writing your initials, it gives us permission to email you from our email account and Solutionreach, our recall system. Please list any other people allowed to speak on behalf of you or granted permission to pick up your contact lense, glasses, etc...