Record Release Authorization Form

Record Release Authorization Form
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Please forward the following documents:*

Prescriptions, glasses and/or contact lenses, onlyDiabetic eye exam report onlyComplete medical and/or eye examination records
Your are requesting documents:*

sent TO Huntley Eye CareFROM Huntley Eye Care
You are requesting documents to be sent TO Huntley Eye Care from the location listed below:
Requesting Documents From Physician/Practice
Physician/Practice Phone Number
Physician/Practice Fax Number
How would you like to receive your documents FROM Huntley Eye Care?
ELECTRONIC copy of COMPLETE eye examination records uploaded to your Patient Portal (There is no additional fee for electronically uploading records to your Patient Portal)PAPER copy of COMPLETE eye examination records. You will need to stop by the office to pick up your records (There is a $1.25 per page printing fee for this option)FAX MOST RECENT eye examination visit to another office
Please stop by the office to determine and pay for the total cost to reproduce a paper copy of your medical records. (No records will be printed until payment has been received.)
Name of Practice
Fax Number
I give my authorization to release the requested dcouments listed above to the provider/practice listed above.
Patient Signature*

Powered by Jotform SignClear
Name of person signing Record Release (if other than patient)

First NameLast Name
Relation to patient
Date

MonthDayYear
Date
Should be Empty: