Record Release Authorization Form

Record Release Authorization Form
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
Please forward the following documents: *

Prescriptions, glasses and/or contact lenses, only Diabetic eye exam report only Complete medical and/or eye examination records
Please forward the requested document (s): *

To Huntley Eye Care, L.L.C. To Another Physician/Practice Location
*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
*You are requesting documents to be sent from Huntley Eye Care TO the location listed below:
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
How would you like to receive your requested documents?

Upload to your Patient Portal (There is no additional fee for electronically uploading records to your Patient Portal) Fax to Physician/Practice Location listed above (There is a $5.00 administration fee for this option)
By providing your credit card information below, you agree for Huntley Eye Care, LLC to charge $5.00 to process your request.

The information sent through this form is HIPAA secured. If you do not wish to provide this information electronically via this form then you must call our office to process this fee; otherwise, your request will not be completed.
Credit Card Number
Credit Card Expiration Date
Credit Card Security Code
Credit Card Zip Code
I give my authorization to release the requested dcouments listed above to the provider/practice listed above.
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
Should be Empty: