Your Journey to Better Vision Starts Here!

Scheduling a FREE, no obligation consultation appointment is a great opportunity to meet your surgeon, ask any questions you have, and find out if you are a good candidate for LASIK.

Authorization to Release Health Information

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • Name and Address of Covered Entity to Receive Information

  • Name and Address of Covered Entity to Release Information

  • The Information Below Will Be Used for Patient Care

  • Date Format: MM slash DD slash YYYY
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  • This authorization shall be in effect until the information has been forwarded as requested.

  • Rights of the Patient

    I understand that I have the right to revoke this authorization at any time by sending a written notification to the address below. I understand that a revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward.

    I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. Any information received by this office for our own use will continue to be protected by the Federal Privacy Rule.

    I understand that I have the right to inspect or copy the protected health information to be used or disclosed as described in this document by written notification to the address below.

    I understand that I have the right to refuse to submit this authorization and that my treatment will not be conditioned on submitting this form.

    Forward requests to:

    CAROLINA OPHTHALMOLOGY ASSOCIATES, P.A.
    Att: Privacy Officer
    55 VilCom Circle, Suite 140
    Chapel Hill, NC 27514

  • By submitting this form, I certify that I have the legal authority to execute this document and that this submission constitutes a legal signature.

“During a free consultation, Pam explained everything they were going to do. The initial tests, the procedure, the cost and financing options were all explained. The upcoming year I set aside money in my medical savings account so I could go forward with the procedure. The actual LASIK process takes literally seconds per eye to complete. I sat up and could see without glasses or contacts immediately!”

Laura A. Hite, RN, BSN, CDE

See what you’ve been missing!

Stop struggling with your eyesight! Now is the time to schedule your free LASIK consultation with Dr. Bryan and Dr. Shaw at Carolina Ophthalmology and find out if you’re a candidate for laser vision correction. Why not take our Self Evaluation Test to get started?