Patient Privacy Notice

  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

  • By signing below, I acknowledge that I have received a copy of the Notice of Privacy Practices form of GRANDVILLE OPTICAL.

    I acknowledge this practice's use of postcards for appointment recall information.

    I acknowledge this practice's phone & internet usage to confirm appointments, request callbacks or give medical information. I understand that reasonable effort will be made to speak directly with me. If I am not available, I grant permission for GRANDVILLE OPTICAL to:

  • Documentation of Failure to Obtain Signed Acknowledgement

  • On __________________, Grandville Optical presented this Acknowledgement of Receipt of Notice of Privacy Practices Form to ______________________________ (the "patient.") The patient refused to provide signature when requested.