MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.
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 patient.
Patient Name:
Birthdate:  

Initials
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)

Initials
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)
Name
Relationship
Name
Relationship
Name
Relationship
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.
Signature of Patient
Date
Signature of Legal Representative of Patient
Date
Printed Name of Patient’s Legal Representative
Date
655 Medical Center Dr. NE
Salem, Oregon 97301
503.581.5287
Fax 503.386.1377
mceyeclinic.com