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Receipt of Notice of Privacy Practices

I, the patient named below, have received a copy of Laster Eye Center's Notice of Privacy Practices.

Patient Name *

First

Last

Signature of Patient *

Date *

Day

Month

Year

Authorization to Disclose Information

I hereby authorize that the Laster Eye Center has my permission to disclose medical and financial information pertaining to my diagnosis and treatment to the following person(s):

Authorized Person 1

Authorized Person 2

Authorized Person 3

Authorized Person 4

Authorized Person 5

Authorized Person 6