Patient name Patient Phone Number Email Address Request / Release Health Information to / from: Office Name Address Fax Phone I authorize the professional office of my optometrist named above to release/receive health information identifying me under the following terms and conditions: Eyeglass Contact Lens Prescription Last Examination Record Entire Medical Record Other Other Description It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form.When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.Date Signature If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:Relationship to Patient Print Name Source of Authority Note: Please allow up to 10 seconds for the form to submit.
