PERMISSION TO RELEASE CONFIDENTIAL MEDICAL INFORMATION
TO A FAMILY MEMBER, FRIEND OR LEGAL REPRESENTATIVE
IMPORTANT NOTICE: The law prohibits release of confidential medical information
without the written, voluntary consent of the undersigned
I AUTHORIZE Medical Center Eye Clinic to discuss information regarding my appointments, my medical
conditions, including results, printing and release of med lists and to leave phone messages on my listed
phone number ( Cell Home) voicemail and/or with any of the following people.
(Please list persons you approved below)
I DO NOT WANT any information given to anyone other than myself, or I want to revoke permission.
(Please list persons you are revoking below)
This authorization can be revoked or updated at any time by the patient in writing or by updating and signing this form.
I understand this authorization. I also understand that the information used or disclosed pursuant to this authorization may be
subject to re-disclosure by the recipient and no longer be protected under federal law. Attach photo ID with signature of patient or
legal representative if not verified with staff at time of signing.