Health Information Release Authorization

Request / Release Health Information to / from:

I authorize the professional office of my optometrist named above to release/receive health information identifying me under the following terms and conditions:




It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.

If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form.

When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:


Note: Please allow up to 10 seconds for the form to submit.

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Check Coverage

Below are links to websites of some insurance providers we contract with. You may check your insurance coverage before your appointment to verify that you are eligible for services or materials.

EyeMed/Aetna (including UC Davis SHIP)

MES

Safeguard

Spectera

Superior Vision

VSP

Quick About

Dr. Guerrieri received his bachelors of science degree from the University of California, Davis in 1981 and his doctor of optometry degree from the University of Missouri, St. Louis in 1986.

Dr. Guerrieri is a member of the American Optometric Association, the California Optometric Association and the Sacramento Valley Optometric Society. He is also a member of the contact lens section of the American Optometric Association and specializes in hard to fit contact lens wearers. He lives out in the country in Davis where he and his wife, Maureen, have raised their four children.

Copyright 2018 Dr. Dennis Guerrieri. All rights reserved