Authorization for Release of Health Information — HIPAA compliant. Complete the form below and we will process your request within 5–7 business days.
This form authorizes ProVision Eye Associates to release your protected health information as specified below. You have the right to revoke this authorization in writing at any time. Submitting this form will open your email client pre-filled with your request details. You may also print this form and fax it to (215) 628-3131 or bring it to our office.
Leave blank if you are picking up records in person or want them sent directly to you.
Leave blank to expire in 1 year from today.
I authorize ProVision Eye Associates to release the health information described above. I understand I may revoke this authorization in writing at any time, except where disclosure has already occurred. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected by HIPAA.
Fax to: (215) 628-3131 · Processing time: 5–7 business days
