• AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION

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  • 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:

  • We are requesting the most recent two years of records unless otherwise specified.

  • 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.

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