corridorfamilyeyecare.com-Medical Records Release Form

Medical Records Release Form

By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical record, or a summary of a narrative of my health information, to corridor Family Eyecare listed below:

Corridor Family Eyecare
5350 Blvd. Ste. 100
Cedar Rapids, IA 52404
319-365-2946 Office
319-365-2948 Fax
www.CorridorFamilyEyecare.com
The information you may release subject to this signed release form is as follow:

Complete Records Care Plans Pathology Reports Hospital Reports History and Physical Lab Reports Treatment Records Medication Record Progress Notes Radiology Reports Operative Reports
Other ( please specify below)
HIV/AIDS: I consent to the release of any positive or negative test result for AIDS or HIV antibodies to AIDS, or infection with any other causative agent of AIDS with the rest of my medical records.
Initial
Date

Month Day Year
Release my protected health information to the following: Corridor Family Eyecare.
The purpose/reason for this release of information is as follows:
I understand that Corridor Family Eyecare will provide this information within 15 days from the receipt of request and that a fee for preparing and furnishing this information may be charged according to rules set forth by the Iowa State Board of Medical Examiners.

Signature:
Signature of Patient or Personal Representative

Clear
Patient Name

First Name Last Name
Name of Personal Representative

First Name Last Name
Description of Personal Representative's Authority
Patient Date of Birth or Social Security Number
Date

Month Day Year
Corridor Family Eyecare Robert T. Kingus O.D.
5350 Kirkwood Blvd. SW Suite 100, Cedar Rapids, IA 52404 Tel: 319-365-2946 Fax:319-365-2948
www.corridorfamilyeyecare.com corridorfamilyeyecare@gmail.com
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