Authorization Release Form

Authorization For Release of Identifying Health Information

Patient Name*
Date of Birth*
Address*
Address Line 2
City*
State*
ZIP Code*
Phone*

I authorize to release health information identifying me (including, if applicable, information about substance abuse, mental health conditions, and HIV infection or AIDS) under the following conditions: Information to be released:

Record requested from:

Full Name
Address
Address Line 2
City
State
ZIP Code

Release information to…

Full Name
Address
Address Line 2
City
State
ZIP Code

I acknowledge Johnson Eyecare PC does NOT utilize secure email and requesting to have my records released to me through their email system could pose a risk to my security and privacy. I will not hold Johnson Eyecare PC responsible for any security breach of my private health record transported in this manner.

Purpose of release
Expiration date for the release (if applicable)

It is completely your decision whether or not to sign this authorization form. We will not refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices.

When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as he/she wishes.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

Representative

Date

Signature*

Upload an image of your driver's license*

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