Patient Authorization For The Disclosure Of Protected Health Information Form

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Wichita Optometry, P.A.
2635 W Douglas | Wichita, KS 67213 | Ph: (316) 942-7496 | Fax: (316) 239-2557
PATIENT AUTHORIZATION FOR THE DISCLOSURE OF PROTECTED HEALTH INFORMATION
* Please complete all items. An incomplete request may result in delay of release of records. Please print. *
__________________________________________________________________________________________
Name of Patient
Date of Birth
_________________________________________________________________________________________ __________________
Street Address
City
State
Zip
Phone
_________________________________________________________________________________________ __________________
Maiden Name or other name used for records
I hereby authorize:
___________________________________________________________________Phone #_______________________
Name of person or place records are requested from
___________________________________________________________________Fax #_________________________
Address of person or place records are requested from
To release to:
___________________________________________________________________Phone #_______________________
Name of person or place records are to be sent to
___________________________________________________________________Fax #_________________________
Address of person or place records are to be sent to
The following information from my records:
o Last Exam; Including most recent tests (VF, OCT, PACH, ETC…)
o Records from time period ___________________________________ to _________________________
o Complete Medical History
___________________________________________________________________________________________________________
What is the purpose of the use/disclosure: oChanging providers-permanent transfer of care oyes ono
oPatient personal use oOther __________________________________
This authorization will expire one year from the date listed below or on ___/___/_____ or occurrence of specified event at which time
this authorization to use or disclose the identified health information expires, but no later than one year from the date listed below.
I, the undersigned, have read the above and authorize the disclosure of such health information as described herein. I understand that
treatment is not conditioned upon the execution of this authorization.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal
privacy regulations, the information described above may be re-disclosed and no longer protected by those regulations.
I understand that Wichita Optometry, P.A. may charge a fee for the costs of copying, mailing, or other supplies and services associated
with this request. I understand Wichita Optometry, P.A. may use a business associate for copying requested medical records as
described in the Notice of Privacy Practices.
I understand that I may revoke this authorization at any time by providing a written notice to the person identified below except to the
extent that action has been taken in reliance upon it or except as otherwise stated in Wichita Optometry, P.A.'s Notice of Privacy
Practices by mailing or hand-delivering written notification to the following person:
Attn: Privacy Officer, 2635 W. Douglas, Wichita, KS 67213.
Wichita Optometry, P.A. is not responsible for completeness, legibility, or omittance caused by the copying of any medical records
from another institution.
__________________________________________________________________________________________
Signature of Patient or Patient Representative
Date
__________________________________________________________________________________________
Printed Name of Patient Representative and Relationship
Patient Representative address and phone number

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