Virginia Oculofacial Surgeons

Name of Patient:*

Date of Birth:*

The office of* is authorized to release protected health information as described below for the identified patient.

Entity to Receive Information.

Check each person or class of persons that you approve to receive information.

Description of information to be released.

Check each that can be given to person/entity on the left in the same section.

Voice Messages on number.*

Appointment Reminders

Other

Spouse or Significant Other:

Appointment Reminders

Treatment Notes and Record

Discuss Treatment

Other Person:

Appointment Reminders

Treatment Notes and Record

Discuss Treatment

Other Person:

Appointment Reminders

Treatment Notes and Record

Discuss Treatment

Patient Rights:

Check each person or class of persons that you approve to receive information.

1. I have the right to revoke this authorization at any time.
2.I may inspect or copy the protected health information to be disclosed as described in this document.
3.Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
4.Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
5.I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing

This authorization will remain in effect until I revoke it in writing.

Full Name of Patient or Personal Representative*

Date*

Signature of Patient or Personal Representative

*Description of Personal Representative’s Authority (attach necessary documentation)

Photographic Consent

1. I,* (print patient’s name) authorize Virginia Oculofacial Surgeons and staff to use photographs of me before and after surgery. I understand these will be used for educational, medical, and possibly promotional use.

2. I consent to photographing of my surgery for these purposes, as approved by the physician.

Date*

Authorization for Release of Protected Health Information

Entity to Receive Information.

Description of information to be released.

Patient Rights:

Photographic Consent