New Patient Medical Record Release Form
ROSENTHALOPTOMETRIC
823 9TH ST
HIGHLAND, IL 62249
618-654-9848
FAX 618-654-5200
AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION
Patient Name_____________________________________________________________
Patient Address___________________________________________________________
Patient Phone Number_____________________________________________________
I authorize the professional office of my optometrist or speciality doctor to release health information identifying me (including if applicable, information about HIV infection or AIDS, information about substance abuse treatment and information about mental health services) under the following terms and conditions:
1. Detailed description of the information to be released
_______Glasses/contact lens prescription
_______Complete medical record
_______Other:___________________
2. To whom may the information be released to (name(s), address(es) and phone):
3. The purpose(s) for the release (if the authorization is initiated by the individual, it is
permissible to state"at the request of the individual" as the purpose, if desired by the
individual):
4. Expiration date or event relating to the individual or purpose for the release:
It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written note telling us that your authorization is revoked.
When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality, In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state and federal law changes this possibility.
I HAVE READ AND UNDERSTOOD THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THIS DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.
Date___________Patient Signature______________________________________________
If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
Relationship to Patient________________________Print Name______________________
Source of Authority__________________________________________________________
