• 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


  • 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.

  •  -  -
    Pick a Date
  • Release my protected health information to the following: Corridor Family Eyecare.

  • 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:

  • Clear
  •  -  -
    Pick a Date
  • 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

  • Should be Empty: