AUTHORIZATION FOR RELEASE OR FOR OBTAINING

IDENTIFYING HEALTH INFORMATION

{Prestonwood Eyecare}

{5425 Beltline Road}

{Dallas, Texas 75254}

{972-980-1772}

{Ximena S. Moiger}, Privacy Official

Patient Name ____________________________________________

Patient Address ____________________________________________

Patient Phone Number ____________________________________________

I authorize {Prestonwood Eyecare} to release health information identifying me (including, if applicable, information about substance abuse, mental health conditions, and HIV infection or AIDS) under the following conditions:

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It is completely your decision whether or not to sign this authorization form. We will not refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices.

When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as he/she wishes.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

____________________________________ ________________

Patient Date

If you are signing as a personal representative of the patient, please indicate your relationship

_______________________________________ ___________________________

Representative Relationship to Patient