Authorization to Release Health Information

Patient First Name

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Patient Last Name

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Date of Birth:

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Address:

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I Hereby Authorize the Disclosure of my Health Information From:

Pediatric Ophthalmology of Erie, Inc.
128 West 12th St. Suite 301, Erie, PA 16501-1743
Phone: 814-454-6307
Fax: 814-454-6397

To Release my Information to:

Name of Person or Organization Receiving Information

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Address:

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City:

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State:

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Zip:

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Phone:

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Fax:

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Information to be Released:

Complete Medical Record

Medical Records for Specific Dates of Service

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Other

Other (Please List)

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This authorization remains in effect until the information has been forwarded as requested.

Rights of the Patient

I understand that I have the right to revoke this authorization at any time by sending a written notification to the address below. I understand that a revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward. I understand information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer by protected by federal or state law. Any information received by this office for our own use will continue to be protected by the Federal Privacy Rule (HIPAA). I understand that I have the right to inspect or copy the proceed health information to be used or disclosed as described in this document by written notification. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

Printed Name of Patient:

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Date:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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