Medical Records Release Request Form

Patient Authorization

Release Medical Records
7405 Shallowford Road, Ste 420

Chattanooga, TN 37421

Phone: 423-855-8522

Fax: 423-855-8533

A copy of this authorization may be utilized with the same effectiveness as an original.
Name of Patient
Date of Birth

Month Day Year
Date
Social Security #
Return Phone Number
Doctor/Facility to PROVIDE records - Check if Allied Eye is to release:

Yes No
Name of Doctor/Facility:
Phone #:
Fax #:
Address:
Doctor/Facility to RECEIVE records - Check if Allied Eye is to release:

Yes No
Name of Doctor/Facility:
Phone #:
Fax #:
Address:
Records TO BE released - Check box indicating which records you would LIKE sent (one box only)

Most recent office visit (free of charge) Up to one year of medical records ($25 fee) Up to three years of medical records ($50 fee) Each additional year after three years of records ($15 fee)
Records NOT TO BE released - Check box/es indicating which records you would NOT LIKE sent

Substance abuse Psychological or psychiatric conditions AIDS/HIV status
Expiration or revocation of authorization: I understand that I may revoke this authorization at any time and that, unless an earlier date is specified, it will automatically expire 12 months after the date below.
Signature of Patient:

Clear
Person authorized to sign for Patient:

Clear
Date:

Month Day Year
Date
Relationship to Patient: (If with Power of Attorney, please attach supporting documentation)
Should be Empty:

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Patient Authorization