I hereby authorize the release of my own or my child's records as described above, including AIDS/HIV (+), sickle cell anemia, behavioral health//spychiatric, drug abuse and or alcohol related information, if applicable. I understand that I Have the legal right to revoke this authorization at any time by notifying Griswold Eye Care, PLLC., in writing, except top the extent that (a) action has been taken in reliance on the authorization or (b) this authorization is obtained as a condition of obtaining insurance coverage other law provides the insurer with the right to contest a claim under the policy or the policy itself. Unless otherwise revoked, this authorization will expire in 90 days or on the following date event or condition:
I understand that authorizing information is voluntary. I can refuse to sign this authorization. | need not sign this form in order to ensure treatment. I understand that I may inspect or have copies made of the information to be used to disclosed. | can contact Griswold Eye Care, PLLC if I have questions about the disclosure of my health information.
By signing below, I acknowledge that I have read and understand this authorization form.