Your Journey to Better Vision Starts Here!

To schedule a cataract evaluation, call us at 919.967.4836 ext 115, or email cataract@carolina2020.com. We look forward to meeting you at your appointment.

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Authorization to Release Health Information

Order Contacts

Patient Information
Patient First Name
Patient Last Name
Patient Date of Birth
MM slash DD slash YYYY
Patient Address Line 1
Patient Address Line 2
Patient City
Patient State
Patient Zip
Name and Address of Covered Entity to Receive Information
Entity to Receive Name
Entity to Receive Address Line 1
Entity to Receive Address Line 2
Entity to Receive City
Entity to Receive State
Entity to Receive Zip
Name and Address of Covered Entity to Release Information
Entity to Release Name
Entity to Release Address Line 1
Entity to Release Address Line 2
Entity to Release City
Entity to Release State
Entity to Release Zip
The Information Below Will Be Used for Patient Care
For Patient Care
- Ophthalmology Records
- All Ocular tests—Visual Field, OCT, photos
- Medical Records for Specific Dates of Service
Patient Care Start Date
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Patient Care End Date
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This authorization shall be in effect until the information has been forwarded as requested.
Consent*

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
Consent*
By submitting this form, I certify that I have the legal authority to execute this document and that this submission constitutes a legal signature.
Relationship If Not Patient
Patient Name
Today's Date
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Other Services Include

“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

Enjoy Life! With better Vision

Stop struggling with your eyesight! Now is the time to schedule your cataract evaluation with Dr. Penke at Carolina Ophthalmology. Why not take our Self Evaluation Test to get started?

Self Examination Test

Your Journey to Better Vision Starts Here!

Authorization to Release Health Information

Patient Information

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

Rights of the Patient

Other Services Include

Enjoy Life! With better Vision