Richmond Eye Associates, P.C.

Notice of Privacy Practices
Written Acknowledgement Form

I, _______________________________________________
(patient's printed name)

have been provided a copy of Richmond Eye Associates' Notice of Privacy Practices and I have had an opportunity to read the Notice.

I authorize Richmond Eye Associates to release my personal health information  to the following individual(s) (Please Print).  You may list as many individuals as you wish:
 

I understand that I may change this list at any time.

______________________

Date