Medical Records Release

MEDICAL RECORDS RELEASE OF INFORMATION CONSENT FORM
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Specific description of the information to be used or disclosed, including the specific purpose:
I authorize FISHER SWALE NICHOLSON EYE CENTER to release the above records TO (name, address, phone and fax):
OR
I authorize the release of the above medical records FROM (name, address, phone and fax):
TO: FISHER SWALE NICHOLSON EYE CENTER

P: 815-932-2020 F: 815-315-4372
EXPIRATION DATE of this authorization:

By signing this form, you authorize the Practice to use and disclose Protected Health Information about you for the reasons mentioned above. You have the right to revoke this authorization at any time, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior authorization. Submit your revocation to the Privacy Officer of the Practice.
Patient Name
Date of Birth
Signature

Clear
Date

MonthDayYear
Date
This authorization was signed by:
Relationship to Patient (if other than patient):
Should be Empty:

MEDICAL RECORDS RELEASE OF INFORMATION CONSENT FORM