ABN+HIPAA FORMS

HIPAA
At Advanced Eye Care Services, we realize patients entrust us with their personal information and we are committed to maintaining this information in a confidential manner. We restrict access to your health information to include only those employees and third parties who need to know to serve your health and vision needs. We maintain physical, electronic, and procedural safeguards to protect your personal information, and all third parties are required to adhere to our strict standards.

HIPAA Compliance Officer
Dr. Daniel Anderson

To help us stay HIPAA compliant, please list below the person/persons who you authorize us to disclose information regarding your Personal Health Information, including billing information. You do not need to list any doctors.
Name
Relationship
Contact Number
Please enter a valid phone number.
Name
Relationship
Contact Number
Please enter a valid phone number.
My signature below signifies that I understand my privacy rights and I understand how my private information may be used by Advanced Eye Care Services. A copy of my privacy rights can be obtained upon request or found online at the provider maintained website.
Signature*

Clear
Date*

MonthDayYear
Date

Signature Page
Print Name
Date of Birth

MonthDayYear
Date
Payment for services is expected and due at the time of your visit. Please acknowledge acceptance of this policy by your initials and signing and dating the form below: *

Clear
Initial
Spectacle/Contact lens prescription release notice: Pursuant to the Federal Trade Commission's ruling 16 CFR Part 315: I understand that the practice will readily supply a copy of my non expired spectacle or contact lens prescription at my request. To abide by HIPM guidelines I understand that this prescription is available to me on my patient portal. The practice will provide access via a registration link to email. *

Clear
Initial
Late Cancellation/No Show Policy: We kindly ask that you provide us with a 24 hour notice for any cancellations. Any appointments that are canceled in less than 24 hours or are missed may be subject to a $25 charge. If more than 10 mins late for your appointment it may be considered a missed appointment. *

Clear
Initial
Signature*

Clear
Date*

MonthDayYear
Date
When you hit "Submit", you will be taken to a new page for more data collection.
Should be Empty:

HIPAA