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Authorization To Protect And Share Your Medical-Information

TrueVision Eye Care

Authorization to protect and/or share your medical information

Please list anyone that you authorize to have access to your (or your dependent’s) medical or financial records. This includes parents, spouses, dependents, domestic partners. If we receive a call regarding prescriptions, records, or financial information and the person is not listed below, privacy laws prevent us from discussing or releasing any information. If you do wish anyone to have access, you MUST list their name below. You may revoke this access at any time in writing. If you do not wish anyone to have access, leave this area blank.

Name ________________________ Relation_______________________
Name ________________________ Relation_______________________
Name ________________________ Relation_______________________

Patient Name __________________________________ Date________________________
Patient/Guardian Signature____________________________________________________

Please print out our form to sign and bring into the office at your next appointment.

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