Authorization for Release of Medical Records from Richland Eye Care

Authorization for Release of Medical Records from Richland Eye Care
Patient Name*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Records to be sent to:*
(Doctor/Office)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Office Tel. Number:*

Area CodeTel Number
Office Fax Number:*

Area CodeFax Number
Appointment Date (if applicable)

MonthDayYear
Date
I hereby grant authorization for the doctors at Richland Eye Care, PLLC to release any and all information from my case records to the above named doctor(s), including glasses and/or contact lens prescriptions, exam findings, and test results.
Patient Signature:

Clear
Special notes/requests:
Should be Empty: