• Record Release Authorization Form

    Record Release Authorization Form

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  • You are requesting documents to be sent TO Huntley Eye Care from the location listed below:

  • How would you like to receive your documents FROM Huntley Eye Care?

  • 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.)

  • I give my authorization to release the requested dcouments listed above to the provider/practice listed above.

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  • Should be Empty: