Dr. Richard A. Goldman
\t\t\t\t\t Shawsheen Vision Associates
\t\t\t\t One Andover Rd.
\t\t\t\t Billerica, MA 01821
\t\t\t\t\t (978) 663-3100

AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION

Patient Name__________________________________________

Patient Number____________________________________________________________________________________________________________________
\t
\tI authorize the professional office of my optometrist named above to release health information identifying me (including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services) under the following terms and conditions.______Patient signature________________________
\tIf you are signing as a personal representative of the patient, describe you relationship to the patient and the source of your authority to sign this form.
Relationship to patient:_________Print Name__________________
\tSource of authority___________________________________

Patient Address

Patient Phone Number

1.\tDetailed description of the information to be released.
2.\tTo whom may the information be released (name(s) or class (es) of recipients.
3.\tThe purpose for the release (if authorization is initiated by the individual, it is permissible to state ?at the request of the individual? as the purpose, if desired by the individual.)
4.\tExpiration date or event relating to the individual or purpose for the release.

It is completely your decision whether or not to sign this authorization form. We cannot
Refuse to treat you if you choose not to sign this authorization.
\tIf you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form.
\tWhen your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes state or federal law changes this possibility.
\tFor marketing authorizations include as applicable: We will receive direct or indirect remuneration from a third party for disclosing your identifiable health information in accordance with this authorization.

\tI HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.
\tDated