KEC Request For Release of Medical Records to Kapolei Eye Care

Request For Release of Medical Records to Kapolei Eye Care
Patient's Name *

First Name Last Name
Patient's Date of Birth *

Month Day Year
Patient's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I hereby request that my medical records be released to:

Kapolei Eye Care

511 Manawai Stt, Unit 401, Kapolei, HI 96707

Ph: (808) 674-2273

Fax: (808) 674-2552
INFORMATION TO BE RELEASED: *

ALL Clinical Records Latest Refraction Visual Fields Glasses Rx Contact Lens Rx Lab Reports Photos
PURPOSE/NEED FOR DISCLOSURE: *

Further Medical Treatment Application for Insurance Payment of Insurance Claim(s) Personal Legal Investigation Vocational Rehab Evaluation
Requesting Records from: *
Physician and/or Facility Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I understand that this authorization shall be valid for six (6) months or revoked through written notice to “Nancy Chen, M.D.” or “Kapolei Eye Care”.

I AUTHORIZE RELEASE OF MY MEDICAL RECORDS IN ACCORDANCE WITH THE SPECIFICATIONS LISTED ABOVE. I UNDERSTAND WRITTEN NOTICE IS NECESSARY TO CANCEL THIS REQUEST.
Signature of Patient or Legal Representative *

Clear
Date *

Month Day Year
If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.
Name of Legal Representative

First Name Last Name
Relationship to Patient
Should be Empty: