Records Release

Central Coast Optometric Center

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

Street Address

Street Address Line 2

CityState / Province

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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*

ToFrom
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*

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