Authorization for Release of Protected Health Information

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.

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:

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.