• AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION

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  • REQUEST TO RELEASE ALL PHI BY ELECTRONIC FILE - PDF FORMAT TO:
    PENNACHIO EYE at the following email address: info@pennachioeye.com

  • I understand I may revoke this authorization at any time. I understand that authorizing the disclosure of this health information is voluntary and is not required as a condition for treatment. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. I understand the information in my medical record may include information relating to sexually
    transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). I also understand it may also include information about behavioral or mental health services, and treatment for alcohol or drug abuse.

    I have requested my PHI in PDF/Electronic format and accept the security risks of possible disclosure breach which may be associated with unsecure, unencrypted e-mail.


    I have read the above foregoing Authorization for Release of Information and acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

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  • Unless otherwise revoked, this authorization will expire on the following date:___. If I fail to specify an expiration date, this authorization will expire 1-year from the date signed.

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