Medical Records Release

Authorization For The Release of Protected Health Information
Bright Eye Consultants PC
Christopher O'Brien MD
6311 Kingston Pike #6W
Knoxville, TN 37919

fax 865.262.8550
voice 865.262.8473
www.BrightEyeConsultants.com
Patient Information
Patient Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Patient Gender*

MaleFemaleOther
Patient Phone*
Please enter a valid phone number.
Patient Phone 2nd
Please enter a valid phone number.
Patient Social Security Number
List all specific doctors or practices from whom records are sought
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent or Authorized Signer
Signer's Relationship to Patient*

Birth ParentSelfLegal GuardianMedical Power of AttorneyOther
Parent or Authorized Signer*

First NameMiddle NameLast NameSuffix
Signer Email Address*
example@example.com

Review & Sign
I, {parentOr107}, the undersigned, request and authorize {listAll}, and my other medical providers to release medical information and records for patient {patientName}, Date of Birth {dateOf}, to Dr. Christopher O’Brien MD and Bright Eye Consultants PC, Fax 865.262.8550, 6311 Kingston Pike, Suite 6W, Knoxville, TN 37919. The purpose of this release is ongoing patient care at Bright Eye Consultants PC.

Please transmit at least the 2 most recent patient exams, operative reports, and the results from any auxiliary testing, such as vision screening, visual field testing, OCT, and IOL Master.

I understand that:
- I may refuse to sign this authorization.
- Refusing to sign this authorization will not affect my treatment, payment, enrollment, or eligibility for benefits.
- I may take back (revoke) this authorization in writing, except for any actions already taken based upon it.
- I understand that this authorization will expire when the records are released for the request dated below. Any requests after this date will need a separate authorization.
- I may request a copy of this form after I sign it.

I, {parentOr107}, attest that I am legally authorized to make healthcare decisions for {patientName}. I have read and understand the above release authorization.
Signature*

Clear
Signed: {parentOr107}

{date} {time}
Date

YearMonthDay
Date
Time

Hour Minutes
Should be Empty: