Farallon Eye Physicians Authorization for Release of Health Information

Authorization for Release of Health Information

Farallon Eye Physicians
Susan Longar, M.D.
Ting Ting Liu, M.D.
Daniel Buckley, M.D.
Peter Martindale, O.D.
1850 Sullivan Ave #500 Daly City, CA 94015
Phone: (650) 992-9221
Fax: {650} 992-9220
Patient Name*

First NameLast Name
Medical Record No.
Healthcare Provider Name*
DOB*

MonthDayYear
Date
Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I Authorize name of provider* to use or disclose my health information to name of provider for the purpose of issue, condition etc.* in the manner described below.
Date of service: The following dates of service(s) to be used or disclosed:

All dates of servicesFrom the ranges of...For the following dates and services
From*

MonthDayYear
Date
To*

MonthDayYear
Date
For these dates and services only:*
Example: May 2020 - June 2022
Type of information: The type of information to be used or disclosed for the dates indicated above is as follows (check the appropriate spaces and include other information where indicated)

Entire medical record
Only the information indicated below:*

Minimum Data SetActivity documentationAssessments, flow sheetsBusiness Office FileCare PlanDiagnostic reports (lab, x-ray, etc.)History and physical, other hospital recordsMedication and treatment recordsEntire billing record(s)Nursing documentation/progress notesNutritional services documentationPhysician and professional consult progress notesPhysician's ordersRehabilitative and restorative therapy documentationSocial Services documentationOther: (Describe as specifically as possible).
Unless I specify differently, this authorization will expire within 160 days from the date of my signature. If you wish to specify a different expiration, insert date or event

MonthDayYear
Date
I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the HIPAA Privacy Rule may no longer protect the information.

I understand that I have a right to revoke this Authorization at any time. I understand that if I revoke this Authorization, I must do so in writing and present my written revocation to the Healthcare Provider listed at the top of this Authorization. I understand that the revocation will not apply to information that has already been released in response to this Authorization.

Unless I specify differently, this authorization will expire within 160 days from the date of my signature. If you wish to specify a different expiration, insert date or event (above)

I understand that Farallon Eye Physicians will not condition the provision of treatment or payment on the provision of this authorization.
Should be Empty: