Authorization for Release of Information to BGOPH

Authorization for Release of Information
Bonner General Ophthalmology

423 N Third Ave. Suite 110 Sandpoint, ID 83864

Phone: (208) 265-1011

Fax: (208) 265-6271
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand this authorization is voluntary. I understand if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
Patient Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
MR#
I hereby authorize Bonner General Ophthalmology to release my health information to:
I hereby authorize Bonner General Ophthalmology to obtain my health information from:
Specific description of information (including date[s])

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Specific description of information (including date[s]):
The patient or the patient’s representative must read and initial the following statements:
1. I understand that this authorization will expire on

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Initials
2. I understand that I may revoke this authorization at any time by notifying Bonner General Opthalmology in writing. It will not have any affect on any actions that were taken prior to the revocation.
Initials
Signature of patient or patient’s representative (Form MUST be completed before signing)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed name of patient’s representative
Relationship to patient
*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION
PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CRF part 2) prohibit you from making further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for release of medical or other information if held by another party is NOT sufficient for this purpose.
Should be Empty:

Authorization for Release of Information

*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION