Records Release Form

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

Patient's Name

Guardian / Authorizing Party's Name (optional)

Patient's Date of Birth

Phone Number of Authorizing Party

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

Information Requested:

Records relating to treatment dates:

From:

To:

Records for all care at this facility or by this doctor.

Other (Please Specify):

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.

Information to be released:

From

Name

Address

City, St Zip

From

Towne Lake Eye Associates
1010 Wyngate Pkwy, Ste 201
Woodstock, GA 30189
770.926.2858 fax 770.926.5106

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.

Signature of Patient or Guardian

Date (Authorization expires in 90-days)

If this authorization is signed by an individual’s personal representative, the representative’s authority is based on: (i.e. state law, court order, etc.)

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.