Authorization for the Disclosure of Medical Information
I hereby authorize Omaha Primary Eye Care to disclose any medical information.
Such information is to be faxed to Omaha Primary Eye Care PC at 4023830780 or mailed to: Omaha Primary Eye Care, PC 14607 W. Center Road Omaha, NE 68144.
This authorization will terminate thirty days from the date noted below.
I understand that if this information is disclosed to a third party, the information may be re-disclosed by the person or entity that received the information and may no longer be protected by federal privacy regulations.