Authorization for Corneal Consultants of Colorado, P.C to Use or Disclose My Health Information

Patient name Phone Number
Date of birth SSN
Name of Physician you see at our Office

I. My Authorization

You, Corneal Consultants of Colorado, P.C, may use or disclose the following health care information:

All my health information maintained by you:
My health information relating to the following treatment or condition:
My health information for the date(s):
Other:

You may disclose this health information to:

Name (or title) and organization Phone
Address City
State Zip

Reason(s) for this authorization (check all that apply):

at my request
other(specify)
check only when Corneal Consultants of Colorado, P.C., will get something of value for providing health information for marketing purposes

This authorization ends:

on(date)
when the following event occurs

**Please allow 72 hours for proccesing**

II. My Rights

I understand I do not have to sign this authorization in order to receive treatment. However, I may be required to sign this authorization form:

I may revoke this authorization at any time, in writing, sent to Corneal Consultants of Colorado, P.C., at the address provide below. If I do, it will not affect any actions already taken by Corneal Consultants of Colorado, P.C., based upon this authorization; uses and disclosures already made cannot be taken back. I may not be able to revoke this authorization if its pupose was to obtain insurance.

Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

I will receive a copy of this authorization after I have signed it. A copy of this authorizaiton is as vallid as the original.

Patient or legally authorized invidual signature Date Time
Patient is unable to sign because of
Printed name if signed on behalf of the patient Relationship & Authority (parent, legal guardian, personal representative, etc.)

III. Additional Consent for Certain Conditions

This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this informaiton can be released.

I consent to have the above informaiton released
I do not consent to have the above information released
Patient or legally authorized individual signature Date Time

IV. Additional Consent for HIV/AIDS

This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Seperate consent must be given to have this information released.

I consent to have the above information released
I do not consent to have the above information released
Patient or legally authorized individual signature Date Time