HIPAA Authorization Form

HIPAA Authorization Form

Authorization of Use and Disclosure of Protected Health Information.
Health information EyeSight Medical Center collects or receives about you may be disclosed to the following people:
#1 Person who may receive information about you:

First NameLast Name
Area Code Phone Number Relationship*
#2 Person who may receive information about you:

First NameLast Name
Area Code Phone Number Relationship
Use and Disclosure of Information:

I authorize the person(s) listed above to receive all health information about my appointments, treatment, and/or other information pertinent to my healthcare and/or payment for my healthcare provided at EyeSight Medical Center.

I do not authorize the following information to be disclosed to any other parties except to me as the patient (please specify):
Add anything you do not want disclosed to the above parties.
Right to Terminate or Revoke Authorization:

You may revoke or terminate this authorization by submitting a written revocation to EyeSight Medical Center

Potential for Re-Disclosure

The person or organization to which health information is sent may repeatedly disclose health information that is identified by this authorization. The privacy of this information may not be protected under the federal privacy regulations.
Name

First NameLast Name
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: