EYEXAM of California Inc.
A Licensed Vision Care Service plan
Authorization for the Release of Personal and Medical Information
I understand and agree that EYEXAM of California, Inc. (EYEXAM) may use and disclose to LensCrafters, Inc. (LensCrafters), an affiliate of EYEXAM, my personal and medical information (including my name, address, member identification number, spectacle and/or contact lens prescription and/or type of products or services provided, prescribed or recommended) to permit LensCrafters to perform administrative services for EYEXAM, provide me with vision care products and services, process my vision care claims, and communicate with me regarding vision care products and services available from EYEXAM or LensCrafters. Information pertaining to me shall not be used for any other purpose.
This Authorization shall remain in effect for a period of four years from the date of this Authorization. I understand that I may revoke this Authorization by notifying EYEXAM, in writing, of my decision to revoke this Authorization. I understand that EYEXAM may not condition treatment, payment, enrollment, or eligibility for benefits on the execution of this Authorization. I understand that LensCrafters has agreed to maintain the confidentiality of all data pertaining to me, but that there is a potential that information which is disclosed pursuant to this Authorization could be subject to redisclosure by LensCrafters. I understand that I have a right to receive a copy of this Authorization.