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:*

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

    Montgomery Eye Physicians & Surgeons

     

    To be released to:

  • Please send:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of birth:*
     - -
  • Format: (000) 000-0000.
  •  
  • Should be Empty: