Authorization To Release Health Care Information Form

Authorization To Release Health Care Information Form

Authorization To Release Health Care Information Form

Authorization To Release Health Care Information Form

Kennebec Eye Care​​​​​​​, P.A.

Authorization To Release Health Care Information

Where records are now:

To receive records:

I

give

its authorized employees and agents permission to disclose the health care information described below relating to:

Purpose of request:

Information to release

Information I REFUSE to release

NOTE: I can refuse to disclose some of my records. Partial or incomplete records will be labeled as such to inform the provider receiving them of their status.

I can revoke my consent to any time prior to the release of records by delivering a written, signed, and dated notice of my wishes to Kennebec Eye Care, P.A.

A decision to withdraw my consent to release records or refusal to disclose some of my records, however, may result in an improper diagnosis or treatment, denial of health benefits or insurance coverage or benefits, or other adverse consequences.

My consent to release my records is effective until:

Authorize re-release of the information. ( A copy of this form is available to sign upon request.)

Signature of patient or legal rep

Relationship to patient

Date

Patient Name

Date of birth

SSAN

Street

City/Town

Zip

chance0524 none 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 9:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM Closed Closed optometrist https://www.google.com/maps/place/Kennebec+Eye+Care/@44.5537945,-69.6342705,17z/data=!3m1!4b1!4m5!3m4!1s0x4cb1e47e5bd98651:0x767e5e6208170243!8m2!3d44.5538151!4d-69.6319013 https://www.facebook.com/KennebecEyeCare/reviews/?ref=page_internal