Records Release

Authorization to Release Protected Health Information
Patient Name:*
Patient Date of Birth:*

MonthDayYear
Patient Address: *
Patient Phone Number:*
Information to be disclosed: Three years of medical information will be provided unless otherwise requested.

All RecordsGlasses RXContact Lens RXTopographyPhotosOther
Purpose of Disclosure:*

Continuing CarePersonal CopyOther
Send Information To:*
Recipient's Address
Recipient's Phone Number
Recipient's Fax Number
Recipient's Email
I understand that:
- This authorization is valid for 90 days after receipt.
- I may refuse to sign this authorization and that it is strictly voluntary.
- I may revoke this authorization at any time in writing, but if I do, it will not have any effect on the actions taken prior to receiving the revocation.
- If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed.
- I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.
I hereby authorize St. Lucy's Vision Center to release medical, psychiatric, alcohol and/or drug abuse, HIV testing, or any other records of a sensitive nature.
Signature of Patient or Patient's Representative:*

Clear
Date*

MonthDayYear
Name of Patient or Patient's Representative Completing this Form:*
Relationship to Patient:
Should be Empty:

Authorization to Release Protected Health Information