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Authorization to Verbally Discuss Protected Health Information*Note: This form is optional. In order for this form to be valid, all information must be completely filled out.
I hereby give permission for Arizona Primary Eye Care and affiliates to verbally discuss the following medical and billing information about me (check all that apply):
Arizona Primary Eye Care and affiliates has my permission to discuss the above information with:
I understand that I may cancel this permission at any time by notifying Arizona Primary Eye Care in writing, however, canceling permission will not affect any information that has already been released.
I understand that I do not have to sign this form and that I should only sign if I want my medical provider or my clinic to share my information with someone.