communityeyecarespecialists

Fax: 814 726 7459
www.communityeyecarespecialists.net
Authorization for Release of Protected Health Information

I hereby give my permission to release medical information as indicated below:
Patient Name
Date of Birth

MonthDayYear
Records are requested for the purpose of

Second OpinionTransfer of CareInsurance PurposesContinuing CareRelocatingOther
If Relocating please provide address
Indicate specific records to be released:

Office Visits / TestingSurgeryAll RecordsLab WorkPathologyImagingOther
If office visits / testing ? dates of Service

MonthDayYear
If surgery ? dates of Service

MonthDayYear
If all records ? dates of Service

MonthDayYear
Release Records to
Fax #

Area CodePhone Number
E-mail
Phone

Area CodePhone Number
Release Records from
Fax #

Area CodePhone Number
E-mail

Area CodePhone Number
Phone

Area CodePhone Number
I understand that this authorization is effective for a period of one year from the date of signature, unless otherwise specified. I understand that I have the right to revoke this authorization at any time by sending a written request to the entity / person I authorized above to release this information.
Patient Signature

Clear
Date

MonthDayYear
Parent (for patients under the age of 18) / Guardian

Clear
Date

MonthDayYear
Name & relationship to Patient
Should be Empty: