All Family Vision Care - Our Focus is on You! | HIPAA Release Form

Contact Us Patient Resources Read Our Reviews Show Locations

All Family Vision Care

Raleigh Hills Vision Clinic

Eye Impressions

Salem Vision Clinic

All Family Vision Care Bend

Doctors

Please fill out all of the form fields as accurately as possible.

HIPAA Release

Patient name:

This field is

This field is

Authorization to Disclose Health Information to Family Members and Friends

I authorize the release of health information to the individuals listed below:

Name	Relationship	Medical	Billing	Make/ Cancel Appointments	Pick up/ Place orders
		Information allowed to disclose(Check all that apply)
This field is	This field is
This field is	This field is
This field is	This field is
This field is	This field is
This field is	This field is

HIPAA Privacy Policy HIPAA Privacy Policy Acknowledgement: I acknowledge that I was offered a copy of Dr. Michael Klautzsch O.D., Dr. Justin Heintz O.D., and Dr. Kelly Shannon O.D. notice of privacy practices.

Patient HIPAA Form: {{ hipaa.first_name }} {{ hipaa.last_name }}

Actions

Come in and see us at any of these four convenient locations!

Corvallis

All Family Vision Care

Tel: 541-757-8844

Portland

Raleigh Hills Vision Clinic

Tel: 503-297-1096

Sherwood

Eye Impressions

Tel: 503-625-0733

Salem

Salem Vision Clinic

Tel: 503-364-0767

Bend

All Family Vision Care Bend

Tel: 541-797-0295

Contact All Family Vision Care

Privacy Practices | Terms of Use

Log in

©2019 All Family Vision Care