ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

Monday: 9:00 AM - 5:30 PM
Tuesday: 9:00 AM - 5:30 PM
Wednesday: 9:00 AM - 5:30 PM
Thursday: 9:00 AM - 5:30 PM
Friday: 9:00 AM - 5:30 PM
Saturday: Closed
Sunday: Closed

Name: Texas State Optical
Address: 1540 Wildcat Dr, Portland, TX, 78374, US
Telephone: (361) 210-3522
Price range: $000 - $300

The law requires that Robert M. Barton, Jr., O.D. dba Texas State Optical 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 Robert M. Barton, Jr., O.D. dba Texas State Optical’s Notice of Privacy Practice and agree to continue my care with Robert M. Barton, Jr., O.D. dba Texas State Optical under said terms.
- I was given to opportunity to read Robert M. Barton, Jr., O.D. dba Texas State Optical’s Notice of Privacy Practices and declined but wish to continue my care with Robert M. Barton, Jr., O.D. dba Texas State Optical under the terms of Robert M. Barton, Jr., O.D. dba Texas State Optical’s privacy policies.
- I have read or had explained to me Robert M. Barton, Jr., O.D. dba Texas State Optical’s Notice of Privacy Practice and do not wish to continue my care with Robert M. Barton, Jr., O.D. dba Texas State Optical 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.
Signature
Date
MM slash DD slash YYYY
If you are signing as a personal representative of the patient, please indicate your relationship
Representative
Relationship to Patient

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