Obtaining Records from another office

AUTHORIZATION FOR THE RELEASE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Obtaining records from another office

Patient Name

Date of Birth

Date

Last 4 of Social Security

Phone Number

City

State

Zip

I authorize Virginia Eyecare Center to:

Receive information from:

Name

Address

City

State

Zip

Purpose of Disclosure

Date(s) of Service and specific information to be disclosed:

Whatever the doctor determines is necessary to properly transition your care (recommended)Other

This authorization will expire:

60 days from date of signatureOther

Statement of Understanding:
➢ I may revoke this authorization at any time in writing, although such a revocation will not apply to information already used or disclosed in
response to this authorization.
➢ Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal
law. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality
Requirements.
➢ I understand and acknowledge that this authorization extends to use and/or disclosure from my medical record, which may include treatment for
physical and mental illness, alcohol and/or drug abuse, and/or AIDS, and/or may include results of an HIV test or the fact that an HIV test was
performed.
➢ Virginia Eyecare Center will not condition the provision of treatment, payment, enrollment, or eligibility for benefits based on the execution of
this authorization.

Signature of Patient or Person Authorized to Consent

Printed Name

Date

Relationship, If not the patient

Thank you for your cooperation.

Virginia Eyecare Center
Phone: (703) 569-3131 Fax: (703) 451-9291
9314-A Old Keene Mill Road
Burke VA 22015
Email: Eyes@VirginiaEyecare.com

Confidentiality Note: The documents that accompany this transmission may contain confidential information. The information is intended only for the use of the individual or entity named above. If you are not the intended recipient, or the person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of the information contained in this transmission is strictly PROHIBITED. If you have received this transmission in error, please notify the sender immediately by telephone or by return email and destroy this transmission, along with any attachments. Thank you.