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.
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