Transfer of Medical Records to Richland Eye Care

Transfer of Medical Records to Richland Eye Care
Patient Name *
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *

Area Code Phone Number
Email
example@example.com
Records to be sent to:

Richland Eye Care, PLLC

8085 N. 32nd Street

Richland, MI 49083

Tel (269) 629-2020 Fax (269) 629-9873
Appointment Date (if applicable)

Month Day Year
Date
Records Requested from: *
Doctor/Office
Office Tel. Number: *

Area Code Tel Number
Office Fax Number:

Area Code Fax Number
I hereby give authorization for the above named doctor to release any and all pertinent information from my case records to the doctors at Richland Eye Care, including glasses and/or contact lens prescriptions, exam findings, and test results.
Patient Signature:

Clear
Should be Empty: