Auth to Discuss Info

Name: Allisonville Eye Care Center
Address: 10967 Allisonville Rd Ste 120, Fishers, IN, 46038, US
Telephone: 317-577-0707
Price range: $000 - $300

Authorization to Discuss Your Information with Family or Caregiver
To comply with the new HIPAA Federal Privacy Regulations, we must receive your written approval to discuss information about you with anyone else including your family, children, and/or caregivers. With your authorization, we will be able to discuss your case, answer questions, leave detailed messages, or contact for other reasons the person(s) listed below. This authorization is optional and you can withdraw it at any time.
Patient Name
First Last
Date of Birth
MM slash DD slash YYYY
Name
First Last
Relationship
Phone Number*
Additional
Name Relationship Phone Number
How to best contact you
Way to contact you: Please Call
- My Home
- My Work
- My Cell
If unable to reach me
- You may leave me a detailed message
- Please leave a message asking me to return your call
The best time to reach me is (day and time)
Phone: Home
Phone: Work
Phone: Cell*
Printed Name of Patient/Guardian
Signature
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Date
MM slash DD slash YYYY
Witness
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Name	Relationship	Phone Number

How to best contact you

Allisonville Eye Care Center