Patient Information

Information to Be Disclosed

Transfer Record From / To:

Recipient

Name of person or class of persons to whom the Practice may disclose my health information:
Alexander Pham, O.D., Samantha Bautista, O.D.
O. Vanessa Avery, O.D., Mark Yeh, O.D.
Laura Tracewell, O.D., Joseph Torres, O.D.
Eye Carumba Optometry

Address to which my health information should be delivered:
Four Embarcadero Center, LL3
San Francisco, CA 94111
Tel: (415) 360-6900
Fax: (415) 772-8222

It is the responsibility of the patient to know and understand their vision insurance benefits. The patient agrees to be responsible for all fees not covered by their vision or medical insurance plan.

Term: This Authorization will remain in effect from the date of this Authorization until the Transferring Practice fulfills the request.

By my signature below, I hereby authorize the Transferring Practice to use or disclose to the recipient my health information for the term of this Authorization for the following specific purpose(s) ("At the request of the patient" is sufficient if the patient is initiating this Authorization):

At the request of the patient.
I understand that once the Practice discloses my health information to the recipient in accordance with the terms and conditions of this Authorization, the Practice cannot guarantee that the recipient will not re-disclose my health information to a third party. Any such third party may not be required to abide by this Authorization of applicable federal and state law governing the use and disclosure of my health information.

I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of the Transferring Practice's treatment of me; except, any revocation will not be effective as to disclosures made in reliance of this Authorization prior to the Transferring Practice’s receipt of my revocation. If my treatment is related to my participation in a research study, I understand that the Transferring Practice may refuse to enroll me in the research study if I do not sign this Authorization.

I understand that this Authorization will remain in effect until the Term of the Authorization expires or I provide a written notice of revocation to the Practice's Office Manager at the address listed below. The revocation will be effective immediately upon the Practice's receipt of my written notice, except that the revocation will not have any effect on any action taken by the Practice in reliance on this Authorization before it received my written notice of revocation.