Release of Medical Records FROM Alaska Children's Eye TO Another Facility

Authorization for Release of Medical Record Information
FROM: Alaska Children’s Eye and Strabismus TO: Another Facility or Personal Use

I give my authorization to use or disclose my protected health care information as described
Patient Name:
DOB:
Previous Name(s):
Patient Address:
Patient Phone Number:
- Disclose health information to:
Name and/or Business:
Address:
*If you would like the medical records sent via HIPPAA compliant secure email, we are able to do so for 10 pages or less.
Email:
example@example.com
• Disclose all the following healthcare information (check all that apply):
Dates:
Other:
Reason for this authorization:
I understand that this authorization is valid for a 1 year period from the date it is signed. I may revoke this consent at any time through written notice.

I have had a chance to read the content of this authorization form and I agree with all statements made in this authorization. Once the office discloses health information the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
Signature of Patient/Parent/Legally Authorized Individual
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name
Relationship to Patient
Should be Empty:

Authorization for Release of Medical Record Information