This form is optional. Please print information if you would like to include someone in your care. Sign and Date at bottom. Please note, if a person is not listed on this form, we will be unable to relay to them any of your health information including test results, appointments, prescriptions, etc.

I authorize the Schein Ernst Mishra Eye to discuss my appointment and/or medical information with another person, please list their name(s) and relationship below.  If you have a Power of Attorney, please document below.  A copy of POA papers must be on file as well. 

I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above:

This authorization will expire at the end of the calendar year, unless you specify an earlier termination. You must submit a new authorization form after the expiration date to continue the authorization.

• You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.
• The practice places no condition to sign this authorization on the delivery of healthcare or treatment.
• We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.

You have the right to receive a copy of signed authorizations upon request.