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 NameLast Name
Patient's Date of Birth:*

MonthDayYear
Patient's Address:*

Street Address

Street Address Line 2

CityState / Province

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

Kapolei Eye Care

511 Manawai Street, Unit 401, Kapolei, HI 96707

Phone: (808) 674-2273

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

ALL Clinical RecordsLatest RefractionVisual FieldsGlasses RxContact Lens RxLab ReportsPhotos
PURPOSE/NEED FOR DISCLOSURE:*

Further Medical TreatmentApplication for InsurancePayment of Insurance Claim(s)PersonalLegal InvestigationVocational Rehab Evaluation
Requesting Records from:*
Physician and/or Facility Name
Address:

Street Address

Street Address Line 2

CityState / 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:*

MonthDayYear
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 NameLast Name
Relationship to Patient:
Should be Empty: