Records Release Form

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

I authorize the use and disclosure of the Protected Health Information for the above named patient as described:


Information Requested:

I understand I have the right to revoke this authorization, in writing, at any time, except (1) where uses or disclosures have already been made based upon my original permission or (2) the authorization was obtained as a condition of securing insurance coverage and the insurer by law has the right to contest a claim or the insurance policy. I understand that uses and disclosures already made based upon my original permission cannot be taken back. To revoke this authorization, I must do so in writing and without my express revocation, this consent will automatically expire 90 days from today’s date. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and no longer protected by the federal Privacy Standards.

I understand that Towne Lake Eye Associates may not condition treatment on my signing this authorization and that I have a right to refuse to sign this authorization. A fax copy or photocopy of this consent shall be as valid as the original.

Fee Schedule: In accordance with state and federal laws, the following fees may be charged to offset the cost associated with the reproduction of records: Base fee of $23.84 plus $0.89/ page for the first 20 pages, $0.77/page for pages 21-100, and $0.60/page for each page in excess of 100 pages.