I authorize the healthcare provider or organization identified above to disclose the medical information specified in this authorization to Guest Malach Eye Specialists.
I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on it. Signing this authorization is voluntary, and my treatment, payment, enrollment, or eligibility for benefits will not be conditioned upon signing except as otherwise permitted by law. Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. I am entitled to receive a copy of this authorization. A photocopy, electronic copy, or facsimile of this authorization may be treated as valid as the original. Unless revoked earlier, this authorization expires one year from the date of signature. By signing and submitting this authorization electronically, I agree that my electronic signature is the legal equivalent of my handwritten signature. I understand that the image of my electronic signature may not appear on printed or PDF copies of this authorization. My electronic signature and the associated date and time of signing are securely recorded with the original electronic submission and remain part of this authorization. I agree that a copy of this authorization indicating that it was electronically signed may be relied upon as evidence of my authorization.