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  • AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 

    I authorize Griswold Eye Care, PLLC to use and/or disclose my protected health information (PHI) as provided below. I understand that I may revoke this Authorization, but the revocation will not apply to information that has already been released in response to this authorization. I understand that my/my child’s treatment is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it. I understand that once the PHI listed below is used or disclosed as set forth in this Authorization, it may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. Please note that each section of the form must be completed in its entirety. Failure to complete a section (including dates) may delay the processing of your request.
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  • FOR GRISWOLD EYE CARE, PLLC. TO DISCLOSE/RECEIVE RECORDS: I authorize Griswold Eye Care to:

  • Information Requested

  • 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.

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