HIPAA AUTHORIZATION FORM
5150 Chappel Dr.
Perrysburg, OH 43551
Patient’s Full Name
Patient’s Date of Birth
Patient’s Telephone Number
City, State, Zip Code
I hereby authorize use or disclosure of protected health information about me as described below.
Modern Heritage Eye Care, LLC is authorized to:
Share discuss with
The following person, class of persons, or facility:
City, State Zip Code
The following personal health information (please give dates of service if possible):
UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL
BE DISCLOSED: YES, DISCLOSE THIS INFORMATION* ______________________
NO, DO NOT DISCLOSE THIS INFORMATION * ______________________
My purpose/use of the information is for:
Continuity and Coordination of Care
Transfer from Practice
Other (explain): _______________________________________________
I understand that my authorization of the requested information is voluntary.
I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and
would then no longer be protected by federal privacy regulations. I understand that my treatment, payment, enrollment, or eligibility for benefits
will not be conditioned on whether I sign this authorization.
I understand that I may revoke this authorization by notifying Modern Heritage Eye Care, 5150 Chappel Dr., Perrysburg, OH 43551, in writing of
my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my
revocation will not affect those actions.
This authorization will automatically expire 90 days following the date of signature OR upon the following date or occurrence of the following
event that relates to me or to the purpose of the intended use or disclosure of information about me: ____________________________________.
Expiration Date: _______________________, 20____ (365-day maximum)
FEES FOR COPIES: Federal and state laws permit a fee to be charged for the copying of patient records. You may be required to prepay
for the copies; if not, then your copies will be mailed along with an invoice.
Date of Individual’s Signature
Signature of Individual*
Date of Birth
(The person about whom the information relates)
OR, if applicable –
Date of Guardian’s/Personal
Signature of Guardian* or
Description of Authority to Act
Personal Representative of Patient’s Estate
for the Individual
Name of Employee Facilitating Request