Limited Patient Authorization for Disclosure of Protected Health Information

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Last 4 of your SSN

MM/DD/YYYY

Entity Requested to Release Information: Associated Eye Care, Inc.

Purpose of request (who will be authorized to receive information) – I attest the entity identified above to disclose or provide protected health information, about me to the individual(s) listed below.

Who will be authorized to receive information? (list the individual/entity who is to receive you PHI, eg. spouse, child, friend):

Person/Entity #1

Person/Entity #2

Description of information to be disclosed – I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above:

check only those items of the record to be disclosed:

Entire patient record

office notes

nursing home, home health, hospice, and other physician records

lab results, pathology reports

record of HIV and communicable disease testing

X-rays

record of mental health or substance abuse treatment

financial history report (previous 3 years only)

other

If you select 'Entire patient record' you do not need to select any additional options.

Write "patient request" or another reason if "other"

You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.
This practice places no condition to sign this authorization on the delivery of healthcare or treatment.
We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.

Patient Name (authorization)