Protected Health Information Privacy Authorization Form
Required by the Health Insurance and Accountability Act - 45 CFR Parts 160 and 164
First and Last Name *
Date of Birth *
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I acknowledge that I have the right to authorize access and disclosure of my Protected Health Information (PHI) to any of my choosing for billing, condition, treatment and prognosis and hereby authorize and request Westchester Eye Care to release my health information (PHI) to: (please include up to three persons: full name and relationship) *
I request the following restriction(s) to releasing my PHI:
Purpose of use:
Clear selection
I understand that I am entitled to a copy of Westchester Eye Care's Notice of of Privacy Practices. I can access a copy of the Notice of Privacy Practices from the website www.westchester-eye-care.com or from the office directly. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not an effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. Unless otherwise revoked this authorization shall be in force and effective five years from today's date at which time this authorization expires. By typing your first and last name below you are agreeing to these terms. *
Today's Date *
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