Records Release From MEPS

Records Release Acknowledgement

I am requesting that my medical records from MEPS to be released. I understand and acknowledge that there may be a preparation fee of $15.00 plus $0.75 for each page. We will contact you to inform you of the amount due.

Please allow up to 14 business days for requests.
Reason for records request: *

Transfer of Medical Care Personal (at my request) Other

I hereby authorize the release of all of my medical records from:

Montgomery Eye Physicians & Surgeons

Dr. Howard Kane | Dr. Yun Ja Park | Dr. Kristen Zeller

To be released to:
Please list the name of the doctor and address you would like your records released to:
Please send: *

All visit notes including visual fields & OCT's Other
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Patient Name: *

First Name Last Name
Date of birth: *

Month Day Year
Date
Patient Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email:
example@example.com
Social Security #:
Example: 123-45-6789
Best contact phone #:
Please enter a valid phone number.
Signature *

Clear
Should be Empty: