Consent Form Consent Form Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920My Authorization:*I authorize the following using or disclosing party, Owen Eye Care, to use/disclose the following health information: All of my health information Health information relating to my treatment/condition Health information covering a specific period of healthcare If you checked "health information relating to my treatment/condition', explain:* If you checked "Health information covering a specific period of healthcare', please list the dates:*From (MM/DD/YY), to (MM/DD/YY) Recipient: Please list family or others authorized to communicate with the doctor on your behalf, pick up orders, view invoices and prescription and health information.The above party may disclose this health information to the following recipient(s):*Please list the person's name, relation to the patient, and phone number. This Authorization Ends:* At my request When I am no longer a patient of Owen Eye Care Signature of Patient*Reset to re-sign.Date* MM slash DD slash YYYY Name of Authorized Representative First Last Date MM slash DD slash YYYY Signature of Authorized RepresentativeReset to re-sign.My Rights:I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.I understand that uses and disclosures already made based upon my original permission cannot be taken back.I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.I understand that I may receive a copy of this authorization, at my request, after I signed it. A copy of this authorization is as valid as the original.
