Records Release

Central Coast Optometric Center

800 Quintana Rd. Ste. 1D, Morro Bay, CA, 93442
REQUEST FOR RELEASE OF MEDICAL RECORDS
Doctor:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Name
Date of Birth

MonthDayYear
Date
Patient's Address at time of service

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purpose of Release
Medical information being requested
Expiration Date

MonthDayYear
Date
I request that my medical records be released
Central Coast Optometric Center

800 Quintana Rd., Ste. 1D

Morro Bay, CA

93442

T: (805) 772-6166

F: (805) 772-5128
Date

MonthDayYear
Date
Name
Patient's Signature or Authorized Representative
Should be Empty: