Get Written Acknowledgement Form - Richens Eye Center

Filling out the WRITTEN ACKNOWLEDGEMENT FORM at Richens Eye Center is an essential step to acknowledge your receipt of their Notice of Privacy Practices. This guide will walk you through the process of completing the form online, ensuring you provide all necessary information accurately.

Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to access the WRITTEN ACKNOWLEDGEMENT FORM and open it for editing.
2. In the first section, provide your full name by printing it clearly in the designated area.
3. Sign the form in the signature field to acknowledge your receipt of the Notice of Privacy Practices.
4. Include the date on which you are signing the form in the specified date field.
5. If you are a parent or legal guardian, locate the section specifically for guardians. Print the name of the patient you are acknowledging for.
6. Indicate your relationship to the patient by checking the appropriate box for 'Parent' or 'Legal Guardian'.
7. Again, sign the form in the signature field to confirm your acknowledgment.
8. Provide the date in the corresponding field as a record of when the acknowledgment is made.
9. Once all fields are completed, review your entries for accuracy, then save your changes, and proceed to download, print, or share the form as needed.

Complete your WRITTEN ACKNOWLEDGEMENT FORM online today!