www.oceyeinstitute.com - Medical Records Release

Medical Records Release

HIPAA Authorization for Use/Disclosure of the health Information
Patient’s Full Name*

First Name Last Name
DOB*

MonthDay Year
Date
Address*
Phone Number*

Area Code Phone Number
Release of Medical Records To:
Name
Fax
Phone Number

Area Code Phone Number
Address
Describe type of medical information
Reason for Disclosure
Date of service

MonthDay Year
Date
Request Medical Information From:
Name
Fax
Phone Number

Area Code Phone Number
Address
Describe type of medical information
Reason for Disclosure
Date of service

MonthDay Year
Date
I understand that I have the right to revoke this authorization, in writing, at any time, except (1) when uses or disclosures have already been made based upon my original permission or (2) the authorization was obtained as a condition or securing insurance coverage, and the insurer by law has the right to contest a claim or insurance policy. I understand that uses and disclosures already made based upon my original permission cannot be taken back. To revoke this authorization, I must do so in writing, and without my expressed revocation, this consent will automatically expire 90 days from today’s date. I understand that the information used or disclosed with my permission may be re-disclosed by the recipient and no longer protected by the federal Privacy Standards. A fax company or photocopy of this consent shall be as valid as the original.
If my medical records include information regarding drug abuse, alcoholism or alcohol abuse, or psychological/psychiatric conditions. I Do I Do Not authorize the release of this information.
***If this authorization is signed by an individual’s personal representative, the representative’s authority is based on (e.g., state law, court order, POA, etc…)
FEE SCHEDULE: States and federal laws specify a reasonable fee may be a charge to offset the cost associated with the reproduction of records. The fee is $25.00 for clerical costs. No fee shall be a charge for reproducing and forwarding records directly to other physicians.
I hereby authorized Orange County Eye Institute, or any of its employee or staff to use and/or disclose the protected health information as specified above.
Patient or Legal Guardian Signature *

Clear
Patient Name*

First Name Last Name
Date*

MonthDay Year
Date
Should be Empty: