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Holly Andersen O. D. Megan Baureis O. D. Privacy Official 100 E. Joyce Suite 104 Fayetteville AR 72703 Phone 479 966-4232 Fax 479 966-4251 Email info uptowneyesnwa.com Authorization for Release of Identifying Health Information HPI Patient Name Date Patient Address Patient Phone DOB The professional office named above is authorized to receive health information from the following clinics 1. If you sign this authorization you can revoke it later except if we have already acted in reliance...
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Holly Andersen O is a form used for reporting financial information.
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