RELEASE OF MEDICAL INFORMATION

RELEASE OF MEDICAL INFORMATION

Please complete each section and sign below.
Patient's Legal Name *
Birth Date *

Month Day Year
Date
Patient's Phone Number *

Area Code Phone Number
Patient's Email *
example@example.com
Name of person and/or institution who will SEND or release the medical records: *
ex: Des Moines Eye Surgeons if you are wanting your records sent from us to a different office.
Phone Number of person and/or institution who will SEND or release the medical records: *

Area Code Phone Number
Fax number of person and/or institution who will SEND or release the medical records:

Area Code Phone Number
Name of person and/or institution who will RECEIVE the medical records: *
Phone Number of person and/or institution who will RECEIVE the medical records: *

Area Code Phone Number
Fax number of person and/or institution who will RECEIVE the medical records:

Area Code Phone Number
Mailing Address of person and/or institution who will receive the medical records:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I would like this information shared by: *

Copies - Mailed Fax Secure Email Verbally Copies - Pick-up in person
Check the information to be disclosed (include dates below if needed) *

**Complete copy of all medical records** All clinic exams Glasses/Contact Lens Prescription History and Visits Medication List Allergy List Problem List (Pt. Summary list) Discharge summary Laboratory Results, specify type or date below X-ray and imaging reports, specify type or date below Test Results (e.g. OCT, Visual Field, etc.), specify type or date below Other, specify below
Specify records or dates needed (or any additional notes for staff):
Please provide a date by which the info is needed (at least 2 business days unless you call ahead): *

Month Day Year
Date
Please check the reason for release below: *

Insurance 2nd Opinion Rehab/disability Personal File Moving out of the area Legal Other Medical Care Transferring Care
This authorization is voluntary. lf I choose to cancel this consent at a later date, I must send written notification to Des Moines Eye Surgeons. If this consent is cancelled, I understand that information may have been released prior to cancellation, and that action would not be considered a breach of confidentiality. I also acknowledge that: 1) recipients of this information may possibly re-release the information without proper authorization, and 2) once information is disclosed it may no longer be protected by federal privacy regulations. I understand that I may review the disclosed information or ask questions by contacting Des Moines Eye Surgeons.

Completion of this form is not requred as a condition of evaluation or treatment. However, when the requested evaluation or treatment is solely for the purpose of creating a medical report for a third party, if authorization to release the information to that third party is not provided, it may result in the cancellation of those services.
I understand that the information may be released electronically, and may include the following categories unless I specifically deny the release:

Substance Abuse Mental Health HIV-related information Genetic tests/info (refers to genetic testing to screen for possibly future heath issues, does not refer to testing to diagnose or treat current health conditions.
Signature of Patient or Legal Guardian (use your mouse to sign or finger) *

Clear
Date *

Month Day Year
Date
Printed name (if not the patient):
Relationship to the patient:
Should be Empty: