Authorization to Discuss Medical Information

I hereby authorize you to use or disclose the specific information described below, only for the purposes and parties described below.

Description of the Information to be Disclosed

Appointment Information

Test Results

Financial

Diagnosis

Summary of Medical Record

Glasses/Contacts Prescriptions

Medications

Care Plan

Other(please specify below)

Other information: (optional)

Patient Name

Date of Birth

Disclose information to the following party/parties:

Name

Date of Birth (optional)

Relationship to Patient

Phone Number

Please fill out the fields below for the recipient of the document(s) you are requesting.

Recipient Name

Recipient Phone Number

Recipient Fax Number

Street Address

Additional Address (optional)

State:

City:

Zip Code:

This authorization shall remain in effect from the date signed below until (please check one):

Expires one year from date of original signature

Until date below, only valid one year from original signature:

Authorization Expiration Date

I understand that:

*I may inspect or copy the protected health information to be used or disclosed.

*I may revoke this authorization in writing by contacting your office.

*This authorization is giving Children's Eye Physicians, Colorado Family Eye Center, and Colorado Center for Eye Alignment the right to discuss any medical information with the person/s above.

*Information used or disclosed pursuant to the authorization may be subject to re-disclose by the recipient and no longer be protected by HIPAA.

*I may refuse to sign this authorization and you will not condition treatment or payment on my providing authorization (except to the extent that the authorization is for research-related treatment, in which case you may refuse to provide that research-related treatment).

Signature:

Date:

Relationship to Patient (if signed by personal representative of patient):