AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

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Patient’s Name:

First

Last

Date of Birth:

Day

Month

Year

Previous Name:

First

Last

Social Security #:

I request and authorize

to release healthcare / vision care information of the patient named above to:

Name

First

Last

Address

Street Address

City

State

Zip

Relationship if patient is a minor or unable to sign.

Patient or Legal

Guardian Signature:

Please type your name as a signature

Date Signed:

Day

Month

Year

Confidential Health Information

Private health care information PHI) is personal and sensitive. It is being released to you after appropriate authorization from the patient or under circumstances that do not require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without additional consent as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties under HIPPA as described in federal and state law.Confidentiality Notice: This message / Information is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable HIPPA law. If the recipient of this information is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is strictly prohibited, and all copies should be destroyed immediately. If you receive this information in error please contact Aldridge Eye Institute (828) 682-2104.

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Confidential Health Information

THIS AUTHORIZATION EXPIRES ONE YEAR AFTER IT IS SIGNED.