Acknowledgement of Receipt of Notice
I understand that Callahan Eye Foundation Hospital is part of an organized healthcare arrangement and that these providers may share my health information for treatment, billing and healthcare operations. I have been given a copy of the organization's Notice of Health Information Practices that describes how my health information is used and shared. I understand the organized healthcare arrangement has the right to change this notice at any time. I may obtain a current copy by contacting the Callahan Eye Foundation Hospital., or by visiting the Web site at www.health.uab.edu/eyes
My signature below constitutes my acknowledgement that I have been provided with a copy of the Notice of Health Information Practices.
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Print (Patient’s Name)
Patient Medical Record Number
Signature of Patient or Legal Representative
Date
If signed by legal representative, relationship to patient:_____________________
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Employee Name Employee Phone Number
UAB Callahan Eye Foundation Hospital
