Sparks Eye Care – Permission to Disclose Medical Information

Sparks Eye Care - Permission to Disclose Medical Information

Patient Name
First Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
- I authorize Sparks Eye Care LLC to discuss or release health information identifying me to the following individuals/entities:
Please provide name and relationship
Name Relationship to Patient
- This authorization to disclose MEDICAL AND FINANCIAL information is being made voluntarily and at my request.
- In signing this authorization, I understand and acknowledge the following (Initial in the space provided):
I understand that this authorization is voluntary and that I may refuse to sign it.
I understand that my refusal to sign this authorization will not affect my ability to obtain treatment, receive payment or eligibility for benefits unless allowed by law.
I understand that I may revoke this authorization at any time by notifying Sparks Eye Care in writing of my intent to do so, except to the extent that action has been taken in reliance on this authorization.
I understand that, unless otherwise revoked, this authorization will expire on the date provided below
Date of Expiration
MM slash DD slash YYYY
I understand that once the disclosures authorized herein have been made, the information disclosed may be subject to re-disclosure by any recipient, and no longer protected by federal privacy law.
I affirm I have read and understand the above information.
Date
MM slash DD slash YYYY
Signature of Patient/Legal Representative
Name of Legal Representative
First Last
Description of Relationship to Member

Name	Relationship to Patient