Dr. Allon Nejatheim and Dr. Edward Lapidus understand that your privacy is important. This notice will help you understand the type of personal information that we may collect, its use and how we protect your privacy in accordance to HIPAA privacy laws.

Acknowledgement of Receipt of Privacy Notice:

By signing this acknowledgement of Receipt of Notice of Privacy practices; I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review, and to keep for my records on the date identified below.

I understand that Allon Vision may use and disclose necessary personal health information (name, address, suscriber ID number, eye exam information and/or type of services provided) to another party to permit the location to perform its administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by Allon Vision ( ex. mailings of exam remainders or information about services/ products provided). I can be assured that Allon Vision does not and will not sell my personal health information of any kind to a third party for such party's own use.

____________________________________ ___________ Patient's signature Date