PHI Waiver – Authorization Form for Release of Personal Information

Park Cities Eye Associates

8115 Preston Road, Suite 630, Dallas, Texas 75225

phone 214-360-9951, fax: 214-360-9819, website:  www.parkcitieseye.com

PHI WAIVER – AUTHORIZATION FORM

FOR RELEASE OF PERSONAL INFORMATION 

Patient Name:             ______________________________________

Patient DOB:              ______________________________________

I authorize Dr. Norton and the staff at Park Cities Eye Associates to disclose confidential protected health information (including but not limited to:  spectacle and contact prescriptions, medical history and eye examination findings and records, billing and fees information, and insurance and claims information) to the person listed below.

Name:                         ______________________________________

Relationship :             _______________________________________ 

This authorization is indefinite (does not expire) unless revoked in writing.  I understand that I may revoke this authorization.  To revoke authorization to the personal listed above, I understand that I must contact Park Cities Eye Associates in writing. 

__________________________________                _________________

Patient Signature                                                        Date

__________________________________                __________________

Witness Signature                                                      Date

__________________________________

Witness Printed Name