This authorization is voluntary. lf I choose to cancel this consent at a later date, I must send written notification to Des Moines Eye Surgeons. If this consent is cancelled, I understand that information may have been released prior to cancellation, and that action would not be considered a breach of confidentiality. I also acknowledge that: 1) recipients of this information may possibly re-release the information without proper authorization, and 2) once information is disclosed it may no longer be protected by federal privacy regulations. I understand that I may review the disclosed information or ask questions by contacting Des Moines Eye Surgeons.
Completion of this form is not requred as a condition of evaluation or treatment. However, when the requested evaluation or treatment is solely for the purpose of creating a medical report for a third party, if authorization to release the information to that third party is not provided, it may result in the cancellation of those services.