Records Release

Authorization to Release Protected Health Information
Patient Name:
Patient Date of Birth:

MonthDayYear
Patient Address:
Patient Phone Number:
Information to be disclosed: Three years of medical information will be provided unless otherwise requested.

Other
Purpose of Disclosure:

Other
Send Information To:
Recipient's Address
Recipient's Phone Number
Recipient's Fax Number
Recipient's Email
I understand that:
- This authorization is valid for 90 days after receipt.
- I may refuse to sign this authorization and that it is strictly voluntary.
- I may revoke this authorization at any time in writing, but if I do, it will not have any effect on the actions taken prior to receiving the revocation.
- If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed.
- I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.
I hereby authorize St. Lucy's Vision Center to release medical, psychiatric, alcohol and/or drug abuse, HIV testing, or any other records of a sensitive nature.
Signature of Patient or Patient's Representative:
Date

MonthDayYear
Name of Patient or Patient's Representative Completing this Form:
Relationship to Patient:
Should be Empty:

Authorization to Release Protected Health Information