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: *

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 Diabetic eye exam report 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
Should be Empty: