AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION

Vision Source Richmond and Vision Source Lake Pointe

Viral Desai, OD

First Name

Last Name

Email address

Phone number

Please check the box:

I authorize to release health information identifying me (including, if applicable, information about substance abuse, mental health conditions, and HIV infection or AIDS) to Vision Source under the following conditions: The Following list of people or office may have access to any Personal Healthcare Information (PHI), at the patient’s request, in order to inform and involve these individuals in the healthcare of the patient. This has no expiration date but may be revoked by the patient at any time by submitting a formal request in writing to our Privacy Officer.

Enter information to whom or where records need to be released:

Release the records to:

Address

Phone number

Fax number

Enter information from where the records need to be released:

Release the records from:

Phone number

It is completely your decision whether or not to sign this authorization form. We will not refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices.

When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as he/she wishes.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

By checking this box and typing my name below, I am electronically signing this acknowledgement.

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Date

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