Authorization to Receive / Release Health Information

Authorization to Receive / Release Health Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize:
Name of Facility / Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
To transfer my information as follows:*

Send my protected health information from the organization listed above to The Eye MDSend my protected health information from The Eye MD to the organization listed above
The Eye MD

1359 Milstead RD NE

Suite 103

Conyers, GA 30012

Phone: 770-691-5176

Fax: 770-692-6126
Information to be release*

Completed Medical RecordLast Office NoteOther
RIGHTS OF THE PATIENT:

I understand that I have the right to revoke this authorization at any time by sending a written notification to the address below. I understand that a revocation is not effective in cases where the information has been used or disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. Any information received by this office for our own use will continue to be protected by the Federal Privacy Rule (HIPPA). I understand that I have the right to inspect or copy the protected health information to be used or disclosed as described in this document by written notification. I understand that I have the right to refuse this authorization and that my treatment will not be conditioned on signing.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: