Privacy Disclosure


I, the undersigned, hereby authorize, upon presentation of this authorization (“Authorization"), Payers and other entities reimbursing health related cost

(Name or Type of Disclosing Entity/Entities)

and its/their business associates to release to: OptMyCare

(Name of Receiving Entity/Entities)

and its authorized employees and agents, copies of: All records

(Description of Records, be specific and clear. Can be “all records")

The purpose for the release of documents is: At the request of the individual

(Describe Purpose. If requested by individual, can be “At the request of the individual")

This Authorization expires: When I notify OptMyCare that I will no longer be using its services

(Expiration date or event)

I understand that the information disclosed under this Authorization may be redisclosed by the person(s) specified above and may no longer be subject to the same protection the information is currently given.

I understand that the information to be disclosed is confidential.  I also understand that by signing this Authorization, I am specifically authorizing the release of health information and records that may be protected by state or federal law or regulations.

I understand that I may revoke this Authorization at any time as explained by the disclosing entity in its Notice of Privacy Practices, except to the extent that action has already been taken in reliance upon this Authorization.  I also understand that I have the right to refuse to sign this Authorization. I also understand that the provision of treatment, payment or enrollment in a health plan or eligibility for benefits may not be withheld based on my refusal to sign this Authorization except in the following cases:
(i) when the release of information under this Authorization is required for a health plan during initial enrollment,
(ii) as part of my participation in a research study; or
(iii) when treatment is provided solely for the purpose of disclosing it to a third party such as a work-related physical done at my employer’s request.

A copy of this Authorization may be used in place of, and with the same force and effect as, the original.

[signatures on following page]

i have read and understand this authorization.  i have received a copy of this form, and i am the individual or am authorized to act on behalf of the individual to sign this document.


Name of Personal Representative (If Applicable)


Signature of Personal Representative (If Applicable)


Description of Personal Representative’s Authority:

Former/Alias/Maiden Name (if applicable)


Date of Birth

Identification Number