Authorization to Release Protected Information

Patient Information
Patient Name*

First NameMiddle NameLast Name
Date of Birth*
Daytime Phone*
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Release Purpose
Check appropriate box or write in other purpose*

Transfer of CareReferralPersonal RecordsLegalInsuranceOther
Release Information FROM
Check one box and complete if applicable

Medical Eye SpecialistsOther, specify organization, department, or individual (complete each line below)
Organization*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Fax*
Release/Send Information TO:
Check one box and complete if applicable

Medical Eye Specialists (300 North Wilson Avenue, Ste. 1003, Bozeman, MT 59715-3551. Fax: 406-587-1092)Other, specify organization, department, or individual (complete each line below)
Organization*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Fax*
This authorization will expire in 1 year from date of signature unless another date is specified:
*

By checking this box I allow the ongoing exchange of information between the above parties until this authorization expires or is revoked.
*

By checking this box I also authorize the release for future visits after the date of my signature until this authorization expires or is revoked
Records to Be Released
Timeframe to Be Released
Document/Note(s) (check all that apply)

Medical RecordsRadiology ReportsOperative ReportsH&P ReportsLaboratory ReportsPhotos & Visual FieldsOther
Delivery Options

MailPick-UpFax (Healthcare Facilities Only)
Signature and Date

The patient or legal representative must sign and date this authorization
I hereby consent to the release of any and all records containing Alcohol/Drug Abuse/HIV/Psychiatric diagnoses under the same consideration as above. I understand that such information cannot be released without my specific consent, except under a Court Order. It is my intent that information released is prohibited for any other purpose than that which is stated above.

Note: A patient (18 years or older) must authorize the release of their own information unless patient is incapacitated or deceased. If signing for a minor patient, I hereby state that my parental rights have not been revoked by a court of law. Specific situation(s) may require minor’s authorization.
Signature*

Clear
Date*

MonthDayYear
Date
Printed Name of Person Signing (if not patient)

First NameMiddle NameLast Name
Relationship if Not Patient (legal documentation of the right of access by the signing individual may be required)

ParentStepparentLegal GuardianFosterPower of attorney/agentOther
Should be Empty:

Patient Information

Release Purpose

Release Information FROM

Release/Send Information TO:

Records to Be Released

Signature and Date