Record Release Authorization Form

Patient Name*

First NameLast Name

Patient Date of Birth*

Date

Please forward the following documents:*

Prescriptions, glasses and/or contact lenses, onlyDiabetic eye exam report onlyComplete medical and/or eye examination records

Your are requesting documents:*

sent TO Huntley Eye CareFROM Huntley Eye Care

You are requesting documents to be sent TO Huntley Eye Care from the location listed below:

Requesting Documents From Physician/Practice

Physician/Practice Phone Number

Physician/Practice Fax Number

How would you like to receive your documents FROM Huntley Eye Care?

ELECTRONIC copy of COMPLETE eye examination records uploaded to your Patient Portal (There is no additional fee for electronically uploading your records to your Patient Portal)PAPER copy of COMPLETE eye examination records (There is an additional fee for paper copies of your records)FAX MOST RECENT eye examination visit to another office (There is no additional fee to fax your most recent visit; however, only the last visit will be faxed)

There is a handling charge of $35.00 per paper copy request in addition to the following charges:

Copy pages 1 through 25	$1.25 per page
Copy pages 26 through 50	$0.75 per page
Copy pages in excess of 50	$0.25 per page

Once we determine the total cost to print your records, we will contact you for payment. Once payment is received, we will notify you when the records are ready for pick up. (No records will be printed until payment has been received)

Name of Practice

Fax Number

I give my authorization to release the requested dcouments listed above to the provider/practice listed above.

Patient Signature*

Name of person signing Record Release (if other than patient)

First NameLast Name

Relation to patient

Date