Text Box: eyecare Associates of Wyoming Daryle L. Clark O.D. Sarah L. Koehn O.D. 312 E. Lakeway Rd. Gillette, WY 82718 307-686-2010 Fax: 307-686-1052 eyecarewy@hotmail.com Office Contact Persons: Dr. Daryle L. Clark, Dr. Sarah L. Koehn AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION Patient name_____________________________________________________________________________________ Patient number___________________________________________________________________________________ Patient address___________________________________________________________________________________ Patient phone number______________________________________________________________________________ I authorize the professional office of my optometrist names above to release health information identifying me (including if applicable, Information about HIV infections or AIDS, information about substance abuse treatment, and information about mental health services) under The following terms and conditions: 1. Description of the information to be released:___________________________________________________________________ 2. To whom may the information be released:_____________________________________________________________________ 3. The purpose(s) for the release:_______________________________________________________________________________ 4. Expiration date or event relating to the individual or purpose for the release:__________________________________________ It 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. 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________________________________Patient signature_____________________________________________________________ If 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_______________________________________________________________________________________________ Text Box: Return to Home Page