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Phyllis Liu, O.D., FCOVD

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HIPAA Acknowledgement

I acknowledge and agree that I have been informed that this office abides by the HIPAA laws. I understand that the Notice of Privacy Practices is posted for review and that I am entitled to a copy to retain for my own records upon request.

I understand that Phyllis A Liu OD FCOVD office may use and disclose necessary personal information such as my name, address, eye examination information to another party to permit the office to perform its administrative duties, provide me with eye care services and products, process vision/medical benefit claims and communicate with me regarding vision care services.

I can be assured that Phyllis A Liu OD FCOVD Office does not sell my personal information of any kind to a third party for any use. I authorize the Office to submit my vision/medical benefit claims to my health plan to receive direct reimbursement for the services and products I received at Phyllis A Liu OD FCOVD Office.

Responsible Party Name(Required)
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