Ginsberg Eye | Medical Records Release Form - Naples  Logo
  • AUTHORIZATION TO RELEASE/OBTAIN HEALTHCARE INFORMATION

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  • to release healthcare information of the patient named above to:

    Name:     Ginsberg Eye

    Address:  77 8th St. S.
                   Naples, FL 34102

    Phone:     239.325.2015    Fax: 239.325.2014

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  • I understand that my authorization will remain effective from the date of my signature for 365 days after, and that the information will be handled confidentially in compliance with all applicable federal laws.

    I understand that I may see the information that is to be sent, and that I may revoke the authorization at any time by written, dated communication. I have read and understand the nature of this release.

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