AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION
Patient Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Cell Phone
The above listed patient authorizes the following healthcare provider to make medical record disclosure as requested:
Type of information to disclose:

All clinical medical records All optical records
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.
Signature

Clear
Date

Month Day Year
Date
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.
Should be Empty: