Medical Record Release

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Medical Record Release

This form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164. Only information specified herein may be released as part of this authorization. Your request to disclose and release this information is voluntary. You may revoke this authorization, in writing, at any time, except where disclosures have already been made based upon my original permission. Uses and disclosures already made based upon your original permission cannot be taken back. Without your express revocation this consent will expire one year from today.

Disclosing Entity

Rocky Mountain Eye Center, Inc.

27 Montebello Rd

Pueblo, CO 81001

Patient Name *

Other Names Used (e.g. Maiden Name)

Social Security Number

Date of Birth *

YYYY

Recipient Entity (Who to Release Records to) *

Eric E. Blom, MD and Skyline Vision Clinic

Scott A. Butikofer, MD and Eye Associates of Pueblo

Paul D. Rastrelli, MD and Skyline Vision Clinic

Nathan R. Stevens, MD and Skyline Vision Clinic

Cory W. Smith, OD and Clear View Vision Center

Myself (via email below)

Other:

Email (only needed for release to patient, parent, or guardian)

Information to Be Disclosed *

My complete medical record

A limited part of my medical record as detailed below

Limitations of Disclosure, Including Start/End Dates (THIS IS OPTIONAL)

Drug or Alcohol Information *

I DO authorize release of information regarding drug or alcohol use, if any.

I DO NOT authorize release of any information regarding drug or alcohol use. I am aware that redaction of my medical record to remove these references may significantly delay the release of my records.

HIV/AIDS Information *

I DO authorize release of information regarding a diagnosis of HIV or AIDS, if any.

I DO NOT authorize release of information regarding any diagnosis of HIV or AIDS. I am aware that redaction of my medical record to remove these references may significantly delay the release of my records.

Mental Health Information *

I DO authorize release of information regarding mental health diagnoses, if any.

I DO NOT authorize release of information regarding any mental health diagnoses. I am aware that redaction of my medical record to remove these references may significantly delay the release of my records.

Purpose of Disclosure

The reason for this authorization is to support my ongoing healthcare needs.

Relationship to Patient *

I am the patient.

I am duly authorized by the patient or by law to execute this release and accept its terms.

Signature (Type Full Name) *

Submit

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