FORM8: Patient Consent to Disclose Personal Health Information

ACKNOWLEDGEMENT
I, {nameas}, authorize EYETELLIGENCE to disclose below mentioned information to undermentioned person who requires the information.

*Please note: A substitute decision-maker is a person authorized under PHIPA to consent, on behalf of an individual, to disclose Ocular health information about the individual.
My Ocular health informationOcular health information of person for whom you are the *Substitute Decision-Maker
Title*
Name of Person for whom you are the Substitute Decision-Maker

First NameLast Name
Ocular health information of you or the person for whom you are the Substitute Decision-Maker
Describe the Ocular health information to be disclosed
PERSON REQUIRING THE INFORMATION
Title*
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone
Fax*
I understand the purpose for disclosing this personal health information to the person noted above. I understand that I can refuse to sign this consent form.
Name*
Patient or Substitute Decision Maker
Signature Date*

MonthDayYear
Signature*

Clear
Should be Empty: