VALLEY EYE SPECIALISTS AND
VALLEY OUTPATIENT SURGICAL CENTER
AUTHORIZATION FORM
FOR OTHER USES OF PROTECTED HEALTH INFORMATION

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you as a patient.  Regulations mandate that we obtain written patient consent before releasing your private health information to family members, caregivers, and/or friends.  This form summarizes the anticipated use of information about you for which this authorization is required.  Valley Eye Specialists, P.L.C. and Valley Outpatient Surgical Center, Inc. provide this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

_____	I have been given a copy of the Notice of Privacy Practices.

I authorize Valley Eye Specialists, P.L.C. and/or Valley Outpatient Surgical Center, Inc. staff to use or disclose information regarding the specific purposes marked below (please check all that may apply).

_____	Obtain information from designated individuals regarding my past and current health history, medications,
            	previous surgeries, billing and/or insurance, and other relevant information.

_____ 	Obtain information from designated individuals regarding my postoperative status, (i.e., postop call).

_____ 	Provide information to designated individuals regarding my surgery/procedure, including preop  instructions, arrival time, date of surgery, and any remaining balances due.

_____ 	Provide information to designated individuals regarding questions about my clinical and/or surgical diagnosis, treatment and care, drop instructions, billing and/or insurance, and surgery (if applicable).

I authorize the following designated individuals to provide and/or obtain information about myself regarding the purposes marked above.

List full name and relationship, phone number, if applicable. _____________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Expiration date of this authorization (circle one):  None  or  Specific Date:  _________________________________

The above mentioned protected health information may be subject to re-disclosure by the party receiving the information and may no longer be protected by the privacy rules.

By signing this form, I authorize Valley Eye Specialists, P.L.C. and/or Valley Outpatient Surgical Center, Inc. to use and disclose protected health information about me for the reasons mentioned above.  I have the right to revoke this authorization at any time, in writing, signed by me.  However, I understand such a revocation shall not affect any disclosures that have already been made in reliance on my prior authorization.  I may submit my revocation to the Privacy Officer at 160 West University Drive, Suite 1, Mesa, Arizona  85201.

____________________________	  ___________________________________          _______________
Printed Name of Patient		  Signature of Patient/Legal Representative	          Date

____________________________	  ___________________________________          _______________
Printed Name of Witness		  Signature of Witness	                                  Date            

Rev.  (F)  8-07-13