Forest Hills Vision Associates, Inc.
I acknowledge that I received the practice’s Notice of Privacy Practices with the effective date shown below. This signature acknowledges receipt only. It is not a separate authorization to use or disclose my medical information.
Patient name: __________________________________________
Notice effective date: September 8, 2026
Date received: _________________________________________
Signature of patient or authorized representative: __________________________
If signed by a representative, name and authority/relationship: __________________________
Please return the completed acknowledgment through the practice’s approved process. Do not send medical information through this website.
