Authorization for Release of Identifying Health Information Patient Name First Last Date of Birth MM slash DD slash YYYY Address Phone NumberI authorize the professional office of __Della Porta EyeCare LLC___ to release health information identifying me [including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services] under the following terms and conditions:1. Detailed description of the information to be released2. Person to whom the information will be released(Required) Della Porta Eyecare, LLC. | 156 Farmington Avenue, Bristol, CT 060103. Reason for the release4. Expiration date of the releaseIt is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form. When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility. Consent(Required) I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.Dated MM slash DD slash YYYY Patient SignatureIf you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:Relationship to Patient Print Name Source of Authority CommentsThis field is for validation purposes and should be left unchanged.
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