Medical Records – Retina Specialists of Beverly Hills

Patient Acknowledgement

I understand this authorization is voluntary. Refusal to sign will not affect my treatment, payment, or eligibility for benefits.

I may revoke this authorization in writing at any time, except where action has already been taken.
Once released, information may no longer be protected by HIPAA but may still be protected under California law (CMIA).
I specifically authorize release of any checked sensitive information (mental health, HIV/AIDS, genetic testing, substance use, etc.).
I understand that I will receive a copy of this signed authorization.Patient Acknowledgement
I understand this authorization is voluntary. Refusal to sign will not affect my treatment, payment, or eligibility for benefits.
I may revoke this authorization in writing at any time, except where action has already been taken.
Once released, information may no longer be protected by HIPAA but may still be protected under California law (CMIA).
I specifically authorize release of any checked sensitive information (mental health, HIV/AIDS, genetic testing, substance use, etc.).
I understand that I will receive a copy of this signed authorization.