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Drs. Pam Thomas, Alaina Medvetz and Eliana Pelfrey (817) 379-6200

Authorization to Use or Disclose
Protected Health Information

Medical Record Release

Office

Patient Full Name

Patient Date of Birth

AT MY REQUEST, I AUTHORIZE:

Shannon Eyecare, P.C. (Dr. Michael Roberts)

5900 Spout Springs Rd, Suite I-9
Flowery Branch GA. 30542
P:770.965.2401/F:770.965.2546

210 Hudson St.
Cumming, Ga. 30040
P:770.887.9171/F:770.887.9180

TO DISCLOSE THE FOLLOWING INFORMATION:
(description of individual health information to be disclosed)
Any and all of the medical records pertaining to the treatment of the individual

PURPOSE OF DISCLOSURE:
At the request of the individual/legal guardian:

I understand that any disclosure of health information carries with it the potential for an unauthorized disclosure and the information may not be protected by federal privacy rules.

I understand that I have the right to revoke this Authorization at any time, except to the extent action has been taken in response to this authorization, by giving written notice of revocation to the practice at the address noted above. I also understand that the revocation will not apply to my insurance company when the law provides any insurer with the right to contest a claim under my policy. (The written revocation must be legible and include the name and date of birth of the individual, the date the revocation is to go into effect, a description of the health information covered by the revocation, the person/entity no longer authorized to receive the information, the signature of the person with legal authority for authorization/revocation, and their phone number.)

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, or my eligibility of benefits.

Unless otherwise revoked in writing, this authorization will expire ONE YEAR from the signature date below.

I certify that I am the patient or legal guardian with the authority to authorize disclosure of this individual’s protected health information.

Signature of patient / legal guardian (type your name)

Relationship to patient (if legal guardian)

Keller Eye Care's Eye Doctors and Staff Provide
Quality Eye Care and Personalized Service You Can Trust

OFFICE HOURS:
MON	9:00 -6:00
TUE	9:00 -6:00
WED	9:00 -6:00
THU	9:00 -6:00
FRI	9:00 -5:00
SAT	By Appt.
SUN	Closed

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Call Today (817) 379-6200

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Keller Eye Care in Keller, TX
Welcome to Keller Eye Care and thank You for visiting our website. We pledge to take excellent care of you and your family by getting to know you on a personal level.

We will make every effort to take a complete approach to your eye care. This means that we will take the time to not only understand your eye health and visual needs, but your general health, lifestyle, and dietary habits as well. This is somewhat rare in health care today, but we think you will find it to be a refreshing change.

Schedule your Eye health and Vision appointment today with our experienced eye care providers at our Keller Eye Care in Keller, TX, Optometrist office and give your vision the level of care and attention it deserves.

You should not have to compromise style for functionality. Regardless of your visual requirements, we have designer frame eyeglasses, sunglasses and contact lenses that will allow you to see great, look great and feel great. Come in and select a style that fits you!

Keller Eye Center has years of education and experience in "hard to fit" contact lens fittings. We take pride in sharing updated technologies and materials with our patients when it comes to meeting their contact lens needs.