Notice to Our Patients

HIPAA:

Federal law passes 1996, The Health Insurance Portability and Accountability Act (HIPAA) mandates our office to notify you of our privacy practices effective as of April 14, 2003. The Purpose of this law is to protect the privacy and security of a person’s health information. Although these practices have always been our policy, it is required that each of our patients is informed and acknowledges receipt of this information.

After reviewing the “Notice of Privacy Practices” carefully, please sign and return this for our office.

Thank you for your cooperation in this matter.

If you have any questions, please contact our Practice Administrator:
(818) 788–9333 or by mail,
16500 Ventura Blvd.
Suite #250
Encino CA, 91436

I acknowledge that I have received a copy of the “Notice of Practice” from the office of The Retina Partners. I have read and understand the information contained in this document.

Signature of Patient or Guardian

Date

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.