• ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

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

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  • If you are signing as a personal representative of the patient, please indicate your relationship

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  • I agree that The Eye Institute of Wyoming, P.C. may disclose certain information of my healthcare to a Personal Representative of my choosing since such person is involved with my healthcare or payments. In that case, The Eye Institute of Wyoming, P.C. will disclose only information that is directly relevant to the person’s involvement with my healthcare or payments.

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