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Patient Support

Authorization for Release of Protected Health Information

Enter a number with at least 10 digits and containing only numeric characters.
Enter a number with at least 10 digits and containing only numeric characters.

I authorize the disclosure of the protected health information as indicated below:

I understand that Retina Consultants of Texas will not place any conditions on my treatment, payment, enrollment in a health plan, or eligibility for benefits based on whether or not I provide authorization or the purpose of disclosure for any of the above information.

I understand that information disclosed pursuant to this authorization may be subject to disclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations.

(if not indicated otherwise, authorization will be effective for 12 months from the date signed)

I understand that I have the right to revoke this authorization at any time by sending written notification to Retina Consultants of Texas to the attention of:

Name: Retina Consultants of Texas, Attn: Medical Records
Address: 4460 Bissonnet Street, Ste. 200, Bellaire, TX 77401
Phone/Fax: 713.524.3434/713.583.2535

I understand that a revocation does not affect any information released according to the terms of this authorization prior to the receipt of the written notification of revocation. Also, a revocation is not effective if this authorization was obtained as a condition of obtaining insurance coverage, as other law provides the insurer with the right to contest a claim under the policy or the policy itself.