HIPAA As part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examinations, and test results, diagnosis, treatments and any plans for future care or treatment. By signing this form, you acknowledge receipt of Orange County Eyecare ' Notice of Privacy Practices .1f you would like a copy of the entire Privacy Act, the staff will provide one for you. I acknowledge that I have been provided with and understand Orange County Eyecare’s Privacy PracticePatient Name:(Required) First Last SignatureDate MM slash DD slash YYYY
