Record Release Authorization Form

Record Release Authorization Form
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
Patient Address

Street Address

Street Address Line 2

City State

Zip Code
Please forward the following documents: *

ALL medical and/or eye records, including ALL prescriptions and ALL diagnostic tests results Medical and/or eye records only Prescriptions, glasses and/or contact lenses, only
Please forward the requested document (s) to: *

Huntley Eye Care, L.L.C. Another Physician/Practice Location
Requesting Documents From Physician/Practice Name
Physician/Practice Phone Number
Physician/Practice Fax Number
Name of Physician/Practice
Physician/Practice Address

Street Address

Street Address Line 2

City State

Zip Code
Physician/Practice Phone Number
Physician/Practice Fax Number
I give my authorization to release all records pertaining to my medical and/or ocular history, services rendered, and treatment given to me to the above address.
Patient Signature *

Clear
Name of person signing Record Release (if other than patient)

First Name Last Name
Relation to patient
Date

Month Day Year
Date
Email (if requesting confirmation of signed Record Release Authorization Form)
example@example.com
Should be Empty: