Limited Patient Authorization for Disclosure of Protected Health Information

This form is not required – Fill this form out if you want someone to have access to your record. EG: Anyone who would call to request information regarding your prescriptions, medical exam, financial, etc. **Please choose which information you’d like to disclose.

*Secure Communication – Note that some fax and email transmission methods are not secure, and it is possible for your PHI to be compromised during transmission from our practice. Do not include a recipient fax number or email if this is of concern to you.

Our forms are secured using 256-bit encryption and our servers meet HIPAA-complaint standards.

"*" indicates required fields

Patient Name*

SSN*

Last 4 of your SSN

Date of Birth*

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

Individual/Entity Name*

Address*

Be sure to include street address, city, state, AND zip code

Phone*

Person/Entity #2

Individual/Entity Name

Address

Be sure to include street address, city, state, AND zip code

Phone

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

Please only send the following*

Purpose of Disclosure*

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)*

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