I understand Ophthalmology Associates may not condition treatment on my signing this authorization and I have
the right to refuse to sign this authorization.
I understand I have the right to revoke this authorization, in writing, at any time, except (1) where uses or
disclosures have already been made based upon my original permission or (2) the authorization was obtained as a
condition of securing insurance and the insurer by law has the right to contest a claim or the insurance policy. I
understand that uses and disclosures already made based upon my original permission cannot be taken back. To
revoke this authorization, I must do so in writing and send it to: OPHTHALMOLOGY ASSOCIATES, 1630
ADAMS STREET, MANKATO, MN 56001.
I understand it is possible that information used or disclosed with my permission may be re-disclosed by the
recipient and no longer by the Federal Privacy Standards.
I authorize release of my medical records in accordance with the specifications listed above. I understand this
authorization is good for one year from this date unless written notification is given.
Spouses or parents of children 18 years of age or older cannot request and/or sign for patient unless he/she is
incapacitated or deceased.
A photocopy of this authorization shall be considered as valid as the original.
Note to Patient: This form is required to comply with the HIPAA Regulations. You must always contact our office
in person to update this release form. Contact by phone or fax is not acceptable.