This authorization must be signed and dated by the person authorized by law to grant this permission.
Please send records for the above named patient to Makar Eyecare, LLC from:
OR Please send records for the above named patient from Makar Eyecare, LLC to:
This authorization is for:
I hereby give my authorization to release a copy of my medical records, reports or test results related to care of myself (or the person named above, for which I have authority to sign for). I understand that this consent expires one year after the date signed below or that I may revoke this authorization in writing sooner if I choose by presenting the provider with a written notice of revocation. If revoked, no actions already taken based upon this authorization will be affected. Information may be re-disclosed if the recipient named on this form is not required by law to protect the privacy information. In such a case, the disclosed information will no longer be affected by federal health information privacy regulations.
Please Note : The information contained in this communication is confidential and intended only for the designated recipient. If you received this communication in error, you are hereby notified that review, dissemination, distribution or copying of this information is forbidden. If you are not the intended recipient, please notify our office immediately by telephone or fax.
All EyeCare Services
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