NECO Center for Eye Care 
Southeastern Massachusetts
450 Pleasant St
East Bridgewater, MA 02333

617-680-8447 Office   857-241-3132 Fax

Authorization for Use and Release of Health Information

Thank you for scheduling an appointment with NECO Center for Eye Care Southeastern Massachusetts, 450 Pleasant Street, East Bridgewater MA, 02333.  We look forward to your visit.
In order to serve you best, it is important that we are be able to review past eye examination reports and history.  To help with this process, please see the attached “Authorization for Use and Release of Health Information” form.  Please fill the form out completely, being sure to obtain the patient's Guardian or Personal Representative signature and date, and send at your earliest convenience (at least three to four weeks prior to the appointment date) to:
Wendy A Vaillencourt
Patient Care Coordinator
 
450 Pleasant St
E. Bridgewater, MA 02333
NECO Center for Eye Care Southeastern Massachusetts
p: 617-680-8447
f: 857-241-3132 
https://www.focusonvisionandvisionloss.org/neco-sema.html

If you should have any questions, please do not hesitate to contact Wendy.  

Thank you so much for your time, attention, and help.

Authorization for Use & Release of Health Information

Patient Name		Date of _Birth	Date Address:				 Patient Phone Number 	

I authorize the NECO Center for Eye Care SEMA clinic to disclose or request my protected health information to the person or class of persons listed below.

Enter where you would like information sent from, and to whom you would like the information to be sent.
FROM: (e.g. hospital, clinic, or provider name):	TO: (e.g. To whom you would like the information sent)	
Name:  		Name:  NECO Center for Eye Care - SEMA		
Address:  		Address:  450 Pleasant Street                                                                                        East Bridgewater, MA 02333		
  Ea	

Tel #:  617-680-8447		
PURPOSE: (Check the appropriate box)	* Copying fees may apply
□	Medical Care	□ Personal
□	Insurance*	□ School
□	Legal Matters*	□ Other (please specify):	SEND BY:
√ Paper Copy via Mail
□	Secure E-Mail (must sign E-Mail consent form on website), write e-mail address below:	

√ Fax (provide Fax # here): 857-241-3132	

□	Most recent contact lens fitting examination/prescription (required for specialty contact lens fittings)
√ All eye care exam notes within the last 12 months	□ Other:  	

□ Entire clinical record

√ Notes from most recent eye examination

Type of Medical Records Requested:
If you would like any of the following sensitive information disclosed, check the applicable box(es) below.

Authorization Agreement
•	I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient and the information may not be protected by federal confidentiality rules.
•	This authorization is voluntary.
•	I decline the opportunity to inspect or copy the information released.
•	My questions about this authorization form have been answered.
•	I understand that I may revoke this authorization at any time by notifying New England College of Optometry Center for Eye Care/New England Eye in writing and that if I choose to do so, my request to revoke will not apply to information that has already been released in response to this authorization.
•	I understand that I may refuse to sign this authorization. My refusal does not affect my treatment, payment or eligibility for care.
•	This authorization will expire 12 months from fulfillment of the request unless I specify a different expiration date or expiration event here:
 	.

Signature of Patient or Personal Representative	Relationship if signed by Personal Rep.

Print Name	Date
Return completed form to: NECO Center for Eye Care SEMA, 450 Pleasant Street, East Bridgewater, MA 02333. Phone: 617-680-8447. Fax: 857-241-3132