Authorization to Disclose Protected Health Information Authorization to Disclose Protected Health Information (PDF) Patient Information:Patient Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Month Day Year Phone*Email* Information to be released from: Grosinger, Spigelman & Grey Eye Surgeons P.C. Facility/Individual Name Facility/Individual Name*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone*FaxInfromation to be release to:* Myself: I request Grosinger, Spigelman & Grey Eye Surgeons to release my protected health information to myself Other: I am the patient, or the legally authorized representative of the patient listed above and request Grosinger, Spigelman & Grey to release the requested protected health information to the named organization or individual below. (If you are requesting records for someone other than yourself, you may be required to provide additional documentation to show that you have a legal right to request records.)Company/Organization*Individual Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFaxEmail Delivery Method* U.S. Mail Pick-Up Requested Data Last Encounter Date Range Date Range From Month Day Year Date Range To Month Day Year Purpose of Disclosure Personal Copy Continuity of Care I understand that: • I must sign this form to obtain records; however, refusal to sign will not affect my treatment, payment, enrollment, or eligibility for benefits. • I may revoke (cancel) this authorization at any time and this release will be considered valid until I provide revocation. • Revocations must be made in writing. Revocations will not apply to information that already has been released and once information has been released, I understand that Grosinger, Spigelman & Grey can no longer protect it from further disclosure. • By signing this release, I understand that the record set may disclose information regarding: alcohol or drug abuse, genetic and/or demographic information, mental health status, serious infectious and communicable diseases (venereal diseases, tuberculosis, Hepatitis C, and HIV infection) which are protected under State of Michigan and Federal confidentiality regulations and cannot be disclosed without my written consent. • Revocations will not apply to insurance coverage or my insurance company to the extent that the law provides my insurer to obtain information in regard to contesting claims under my policy or the policy itself.Signature of Patient or Legally Authorized Representative*Name of Patient or Legally Authorized Representative* First Last PhoneThis field is for validation purposes and should be left unchanged. Δ
