Records Release Form Please fax all medical records including patient notes, visual fields, images and OCTs To: Eye Consultants of Savannah, Office of Dr. Lily Hipp and Dr. David D. Kim Fax: (912) 218-3335. I am requesting this to be sent from: * * Do not type Eye Consultants of Savannah Name * First Name Last Name Date of Birth * MM DD YYYY Phone Number * Email * CONSENT : I hereby authorize the release of all records on file related to my health or well-being, which may or may not include protected health information (PHI) and electronic protected health information (ePHI) protected under HIPAA. The purpose of release is transfer of care. I acknowledge that my refusal to sign this authorization will not affect my ability to obtain treatment, nor will it affect my eligibility for benefits. I acknowledge the rights granted to me under HIPAA allow me to revoke this authorization at any time, provided that such revocation is in written format. I acknowledge that any released PHI or ePHI may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I acknowledge this authorization is vald for a period of 90 days. I grant my consent and request the release of the following: All Medical Records Including patient notes, visual fields, images and OCTs To: Eye Consultants of Savannah, Office of Dr. Lily Hipp and Dr. David D. Kim Fax: (912) 218-3335 4849 Paulsen St, Suite 312 Savannah, GA 31405 * * I Consent Thank you!
