Authorization for Release of Medical Records

Please print all information. Form must be signed and dated.

Patient Name

SEME Account #

Date of Birth

Date

Entity Requested to Release Information

Purpose of request (who will be authorized to receive information) - I authorize the entity identified above to disclose or provide protected health information, about me to the individual/entity listed below.

Who will be authorized to receive information (the individual/entity whom is to receive your PHI):

Individual/Entity Name:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

Fax

Email

* Secure Communication - Note that regular email is not secure, and it is possible for your PHI to be compromised during transmission from our practice. Do not designate email as your preferred method of disclosure if this is of concern to you. Description of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above:

Entire patient record; or, check only those items of the record to be disclosed:

Standard Medical Records (includes clinical exams and progress notes for the last 3 years)Eyeglass PrescriptionsContact Lens PrescriptionsPrinted Images with interpretationLab/MRI/CT ResultsFinancial history report (previous 3 years only)Surgical ReportsRecords older than 5 years

For records older than 5 years, please specify dates

Purpose of disclosure (please record the purpose of the disclosure or check patient request):

Patient RequestOther

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.

Please list the date of expiration if earlier than the end of the calendar year

Date

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.

Patient or authorized representative signature

Clear

Date