Authorization To Release Protected Health Information

  • To help our staff best prepare for your visit, please request that records form your prior optometrist and/or retinal specialist are sent to our office.
  • Date Format: MM slash DD slash YYYY
  • Where should we request your records from?
  • By signing below I authorize all listed individuals and/or practices to disclose the following Protected Health Information to/from Heritage Eye Care, Dan Yoakum O.D., P.A. I understand that once the information is release it may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. I understand that I may revoke the authorization at any time by notifying, in writing, the above-named doctor and/or medical practice prior to their receipt at the revocation. This authorization expires withing two years unless noted on the form otherwise.
  • Today's Date: 01/28/2021