Authorization to Use or Disclose
Protected Health Information
Medical Record Release
Patient Full Name
Patient Date of Birth

AT MY REQUEST, I AUTHORIZE:

Grafton Eye Center (Kristopher Knous O.D.)

950 N. Port Washington Rd.
Grafton, WI 53024
P:(262) 204-1063 / F:(262) 204-1064

TO DISCLOSE THE FOLLOWING INFORMATION:
(description of individual health information to be disclosed)
Any and all of the medical records pertaining to the treatment of the individual

PURPOSE OF DISCLOSURE:
At the request of the individual/legal guardian:

I understand that any disclosure of health information carries with it the potential for an unauthorized disclosure and the information may not be protected by federal privacy rules.

I understand that I have the right to revoke this Authorization at any time, except to the extent action has been taken in response to this authorization, by giving written notice of revocation to the practice at the address noted above. I also understand that the revocation will not apply to my insurance company when the law provides any insurer with the right to contest a claim under my policy. (The written revocation must be legible and include the name and date of birth of the individual, the date the revocation is to go into effect, a description of the health information covered by the revocation, the person/entity no longer authorized to receive the information, the signature of the person with legal authority for authorization/revocation, and their phone number.)

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, or my eligibility of benefits.

Unless otherwise revoked in writing, this authorization will expire ONE YEAR from the signature date below.

I certify that I am the patient or legal guardian with the authority to authorize disclosure of this individual’s protected health information.

Signature of patient / legal guardian (type your name)

Relationship to patient (if legal guardian)



OFFICE HOURS    
Mon
10:00 - 5:00
Tue
9:00 - 5:00
Wed
10:00 - 5:00
Thu
9:00 - 4:30
Fri
10:00 - 4:30
Sat
 9:30 - 3:00
Sun
By Appt.
Inside Costco
950 N. Port Washington Rd,
Grafton, WI 53024
(262) 204-1063
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Grafton Eye Center 950 N. Port Washington Rd. Grafton, WI 53024 Phone: (262) 204-1063 Fax: (262) 204-1064

Grafton Eye Center is proud to serve Grafton, Saukville, Mequon, Cedarburg, Port Washington, Fredonia, Germantown, Sheboygan, Brown Deer, and West Bend.

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