ACKNOWLEDGEMENT

OF

NOTICE OF PRIVACY PRACTICES

The law requires that {Prestonwood Eyecare, David C. Moiger, O.D.} make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

¨ I have read or had explained to me {Prestonwood Eyecare, David C. Moiger, O.D.}’s Notice of Privacy Practice and agree to continue my care with {Prestonwood Eyecare, David C. Moiger, O.D.} under said terms.

¨ I was given to opportunity to read {Prestonwood Eyecare, David C. Moiger, O.D.}’s Notice of Privacy Practices and declined but wish to continue my care with {Prestonwood Eyecare, David C. Moiger, O.D.} under the terms of {Prestonwood Eyecare, David C. Moiger, O.D.}’s privacy policies.

¨ I have read or had explained to me {Prestonwood Eyecare, David C. Moiger, O.D.}’s Notice of Privacy Practice and do not wish to continue my care with {Prestonwood Eyecare, David C. Moiger, O.D.} under said terms.

¨ The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as

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

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Patient Date

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

___________________________ _____________________

Representative Relationship to Patient