EYEZ10 Request to Release Information Form

REQUEST EYE CLINIC OF AUSTIN TO RELEASE INFORMATION TO ANOTHER PARTY

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Dear Patient:
Our Notice of Privacy Practices provides information about our use of a patient’s protected health information. The Notice contains a Patient Rights section describing your rights under the law. Patients have the right to access, inspect, and copy protected health care information used to make decisions about them. The Eye Clinic of Austin uses and provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Eye Clinic of Austin will only include information used to make decisions about the patient. We will limit access to information generated only by this Practice. Under some circumstances, such as increased risk of harm or injury, the Practice may withhold the requested information. A Compliance Officer (or designee) of this Practice will evaluate this request and notify you of our decision within fifteen (15) days. Reasonable costs will be charged for the request. Costs will be submitted to the patient (or agent) upon approval of the request. The Practice may provide a summary of the requested information if you are agreeable.

Dear Compliance Officer:

I would like to request from and authorize the Eye Clinic of Austin to release a copy of my medical records as indicated below to myself or the party indicated.I would like to arrange an appointment to inspect the request information.I understand that there will be a cost charged to me (or my agent) for this service. I agree that a photocopy of this authorization may be considered valid and that this authorization shall be valid for 90 days from the date of my signature. I understand my rights and the Eye Clinic of Austin’s policies regarding this release, as indicated above, and in the Notice of Privacy Practices.

Health Care information requested: Please provide dates, diagnosis, treatment and any other indications of the specific information you desire.

Is a summary of the information acceptable?

YesNo

Instructions regarding information requested:

I will pick up the copy when I have been notified that is it readyPlease mail the information to the following address below:

Name of Recipient

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Fax

Please enter a valid phone number.

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/Guardian/Legal Representative Signature*