Ginsberg Eye | Medical Records Release Form

For the purpose of patient care, I hereby request and authorize the following organization or individual to release my records to (please fill in blank) as specified in this release.
(name of organization or individual authorized to release or obtain PHI)
AUTHORIZATION TO RELEASE/OBTAIN HEALTHCARE INFORMATION
Patient's Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous Name
Social Security #
I request and authorize:
(name of organization or individual authorized to release or obtain information)
to release healthcare information of the patient named above to:

Name: Ginsberg Eye

Address: 77 8th St. S.
Naples, FL 34102

Phone: 239.325.2015 Fax: 239.325.2014
This request and authorization applies to - Healthcare information relating to the following treatment, condition, or dates:
All healthcare information - other:
Patient/Representative Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Relationship to Patient
Witness
I understand that my authorization will remain effective from the date of my signature for 365 days after, and that the information will be handled confidentially in compliance with all applicable federal laws.

I understand that I may see the information that is to be sent, and that I may revoke the authorization at any time by written, dated communication. I have read and understand the nature of this release.
Patient Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

AUTHORIZATION TO RELEASE/OBTAIN HEALTHCARE INFORMATION