KEC Medical Record Release Authorization Form

Authorization for Kapolei Eye Care to Use or Disclose My Health Information
Patient's Name *

First Name Last Name
Patient's Date of Birth *

Month Day Year
Social Security # *
I. My Authorization

You, Dr. Nancy Chen and/or Kapolei Eye Care, may use or disclose the following health care information:
*

All my health information maintained by you My health information relating to the following treatment or condition *specify below My health information for the following date(s) *please specify below
Specify here:
*treatment relating to condition or specific date range of medical records
You may disclose this health information to: *
Name (or title) and/or Organization
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Fax Number

Area Code Phone Number
Reason for this authorization: *

at my request
II. My Rights

I understand I do not have to sign this authorization in order to receive treatment. However, I may be required to sign this authorization form:

To take part in a research study; or
To receive health care when the purpose is to create health information for a third party.
I may revoke this authorization at any time, in writing, sent to Nancy Chen, M.D. and/or Kapolei Eye Care at the address provided below. If I do, it will not affect any actions already taken by Nancy Chen, M.D. and/or Kapolei Eye Care based upon this authorization; uses and disclosures already made cannot be taken back. I may not be able to revoke this authorization if its purpose was to obtain insurance.

Nancy Chen, M.D., Kapolei Eye Care
511 Manawai St, Unit 401, Kapolei, HI 96707
Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

This authorization is valid for one year from date signed.
Patient's Signature *

Clear
Date *

Month Day Year
If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.
Name of Legal Representative

First Name Last Name
Relationship to Patient
Should be Empty:

Authorization for Kapolei Eye Care to Use or Disclose My Health Information