CHIZ27 Records Release Form

RECORDS RELEASE

I AUTHORIZE AND REQUEST
Children’s Eye Care

TO SEND ALL OF MY RECORDS TO (THE RECEIVER):
(this is who you want the records to go to)

Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

By my signature, I authorize that my protected health information (PHI) may be used or disclosed by the sender. I authorize my PHI to be forwarded to the receiver. I understand that the PHI, which is used or
disclosed pursuant to this Authorization, may be subject to re-disclosure by the recipient and may lose the protection of confidentiality under the privacy rules. I understand that I have the right to inspect and copy the
PHI that will be used or disclosed pursuant to this Authorization. I understand that the sender and receiver will not condition any aspect of my treatment, payment, enrollment in the health plan or eligibility for
benefits on whether or not I sign this Authorization. I understand that I am under no obligation to sign this Authorization. I understand this authorization will expire 60 days after the date I signed it. I understand that this Authorization may be revoked in writing at any time. By my signing the Authorization, I acknowledge that I have read and understand this Authorization. Further, I give my authorization to the sender to use or disclose PHI in accordance to the terms of the Authorization.

Patient's Name*

First NameMiddle NameLast Name

Patient's Date of Birth*

Date

Patient's Social Security Number

Additional Comments

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

PATIENT/PARENT/GUARDIAN’S SIGNATURE

PARENT/GUARDIAN’S NAME (IF APPLICABLE)

First NameLast Name