Privacy Statement The Privacy Act of 1977 was established to protect your privacy and to give you security in knowing that when you come to our office, your medical and financial affairs will not be disclosed with anyone without your permission. This includes your spouse and/or family member(s).It is a felony for our staff to give out this information without your written consent. Please take a moment and list anyone whom you would like to give us permission to discuss your personal health information with.I am the undersigned give permission for the staff of Morgan Vision care to release medical/financial information to : Who is my SignatureI am the undersigned give permission for the staff of Morgan Vision care to release medical/financial information to : Who is my SignatureI give permission to leave a verbal message at my personal residence. Yes No I give permission to leave a message regarding my appointment on my voicemail. Yes No Thank you for your assistance with this matter. Patient SignatureDate MM slash DD slash YYYY