Release of Medical Records FROM Another Facility TO Alaska Children's Eye and Strabismus

Authorization for Release of Medical Record Information
FROM: Another Facility or Personal Use TO: Alaska Children’s Eye and Strabismus

I give my authorization to use or disclose my protected health care information as described
Patient Name:
DOB:
Previous Name(s):
Patient Address:
Patient Phone Number:
Disclose health information to:

Name and/or Business: Alaska Children’s Eye and Strabismus
Address: 3500 LaTouche St. Suite 280 Anchorage, AK 99508
Disclose all the following healthcare information (check all that apply):

All my health informationOperation Notes
Dates:
BillingOther
Other
Reason for this authorization:
I understand that this authorization is valid for a 1 year period from the date it is signed. I may revoke this consent at any time through written notice.

I have had a chance to read the content of this authorization form and I agree with all statements made in this authorization. Once the office discloses health information the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
Signature of Patient/Parent/Legally Authorized Individual

Clear
Date:

MonthDayYear
Date
Printed Name
Relationship to Patient
Should be Empty:

Authorization for Release of Medical Record Information