Authorization for the release of patient medical records from Dr. Rubinfeld’s offices to another healthcare provider.

This Authorization form is designed to meet the requirements of federal privacy regulations issued by the Department of Health and Human Services at 42 CFR § 164.508 and the Annotated Code of Maryland, Title 10 Health General Article §§ 4-301-4-307.

Medical Record Request
Patient Address
Patient Address
Doctor Address
Doctor Address

This authorization is voluntary. This request may take up to 48-72 business hours. My treatment, payment for it, and/or eligibility for enrollment or benefits cannot be conditioned on my signing this authorization form.

  • I may receive a copy of this form.
  • I may inspect my protected health information without signing this form.
  • This authorization to disclose information may be revoked by me at any time, expect to the extent that the action has been taken prior to receipt of revocation. To revoke the authorization, I understand that I must notify Re:Vision in writing.
  • I understand that once information covered by this authorization has been disclosed re-disclosure of information by that recipient is possible and the information may no longer be protected by the federal regulations referenced above but may be protected by Maryland law.

I agree to these terms and conditions.