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Medical Plaza

Panther Creek

Home » Patient Portal » Request for Release of Medical/Billing Records

Request for Release of Medical/Billing Records

  • I can revoke this authorization in writing at any time. This authorization remains in effect until such notice is given.
  • Patient Info

  • I authorize George C. Kaufman, III, ODPA, DBA: Woodlands Eye Associates to release health information/billing records identifying me (including, if applicable, information about substance abuse, mental health conditions, genetic information, and HIV infection or AIDS) under the following conditions:
  • Recipient Info

  • Billing/Financial Release: Includes Transaction History and Billing Statements:
  • Authorization to release information to my Parent(s) Guardian(s):
  • It is completely your decision whether or not to sign this authorization form. We will not refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices.

    When your health information is disclosed under this authorization, the recipient has no duty to protect it’s confidentiality. The recipient may re-disclose the information as he/she wishes.

  • If you are signing as a personal representative of the patient, please indicate your relationship.

  • This field is for validation purposes and should be left unchanged.