Send Records to POA

Patient Information

Full Name

Address

Other Information:

1. As described in the Notice of Privacy Practices of Pediatric Ophthalmology Associates, Inc., I understand that I may revoke

this authorization in writing at any time, except to the extent that action has been taken by Pediatric Ophthalmology Associates,

Inc. in reliance on this authorization, by sending a written revocation to Pediatric Ophthalmology Associates, Inc 555 S. 18th St

4-C Columbus, OH 43205 ATTN: Privacy Officer.

2. In understand that I am not required to sign this authorization form and that Pediatric Ophthalmology Associates, Inc. will not

 condition the provision of treatment t or payment to me on the signing of this form.

3. I understand that in this authorization includes the use and/or disclosure of information from the patient medical or financial

 records as specified above. This authorization includes the use and/or disclosure of information concerning HIV testing or

 treatment of AIDS or AID related conditions, any drug or alcohol abuse, drug-related conditions, alcoholism, and/or

 psychiatric/psychological conditions to the above mentioned entity(s).

4. I understand that if the person or entity that receives the above information is not a health care provider covered by federal

privacy regulations, the information described may be redisclosed by such person or entity and will likely no longer be

protected by federal privacy regulations.