Medical Release Form – Consent 2022 Patient's Name: Date of Birth MM slash DD slash YYYY Consent and Authorization to Release or Discuss Protected Health Information Release of Information: I consent to the release and use by Kennedy Vision Health Center (referred to as “KVHC”) of medical and other information about me to the extent permitted by law to the following: To a health care provider being advised or consulted in connection with my treatment or care; To a health plan, insurer, third party payor, third party administrator or other organization providing me with health benefits, for the purposes of claims payment and benefit determinations, fraud investigations, or quality of care studies or reviews; and To a person or organization in connection with KVHC’s health care operations. These operations may include interdisciplinary care conferences, quality improvement activities, performance evaluations, business management, and other related activities. To the following individuals (name spouse, family member, employer, or any other individual): 1: Relationship: 2: Relationship: 3: Relationship: Consent I do not want my information shared with another party or individual (INC. INSURANCE) Revocation: I understand that this consent shall continue until I revoke it, which I may do at any time by giving written notice to KVHC. Once my information is shared with the person/s named above, it may no longer be protected by privacy laws. Kennedy Vision Health Center cannot prevent these persons from sharing my information with a third party. Signature of Patient (if applicable): Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Signature of Legal Guardian (if applicable): Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.