Release Records From ECNC

AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION
Patient Name*

First NameLast Name
Previous Name

First NameLast Name
Phone Number
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Date of Birth*

MonthDayYear
Date
OBTAIN RECORDS FROM:

Eye Center of Northern Colorado
3151 Precision Drive
Fort Collins, CO 80528
970-221-2222 Phone
970-221-4286 Fax
RELEASE RECORDS TO:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
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Fax
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We are requesting the most recent two years of records unless otherwise specified.
Comments
I hereby authorize the Eye Center of Northern Colorado, P.C. to obtain the specified information as stated in this authorization. I understand that the information in my health record may include information relating to sexually transmitted diseases, HIV/AIDS, mental health and drug or alcohol abuse. We will not include records from other doctors’ offices. I hereby release the Eye Center of Northern Colorado, P.C. and its employees from any and all liability that may arise from the release of information as I have directed. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Without my express revocation, the authorization will automatically expire one year from the date of signature.
Patient Signature

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Date Signed

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Date
Parent/Guardian Signature

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Date Signed

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Date
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AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION

RELEASE RECORDS TO: