Hipaa Medical Release Form - Eye Center South

Medical Information Release Form

HIPAA Release Form

Name:________________________________ Date of birth:________

Release of Information

( ) I authorize the release of information including medical diagnosis and

examination records rendered to me and claims information. This information

may be released to:

( ) Spouse _______________

( )Child (ren) _____________

( ) Other ________________

( ) Information is not to be released to anyone.

This Release of Information will remain in effect until terminated by me in

writing.

Messages

Please call ( ) my home ( ) my work ( ) my cell The number is ______________

If unable to reach me: ( ) you may leave a detailed message

( ) please leave a message asking me to return your call

( ) other _______________________________________

The best time to reach me is _____________

Signed:____________________ Date:_______

Witness:__________________ Date:_______

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Parent category: Medical