mcdonaldeyecare.com- RELEASE OF MEDICAL RECORDS AUTHORIZATION FORM

Patient Information:
Patient Name:
Patient Date of Birth:

MonthDayYear
Address:

CityState / Province

Postal / Zip CodeCountry
Home Phone#:
Work Phone#:
Ext:
Cell Phone#:
I am requesting my medical records be released from:
Clinic/Doctor:
Address:

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone#:
Fax#:
I am requesting my medical records be released to:
Physician/Clinic/Other:
Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone#:
Fax#:
Please check ONE of the following:
I wish to obtain a summary of the requested recordsI wish to inspect the requested records (in the office)I wish to obtain a copy of the requested records (fees may apply with this option)I wish to inspect and obtain a copy of the requested records (fees may apply with this option)I wish to communicate electronically* knowing that standard email and text communication may not be totally secure, I still consent to communications from my doctor or staff through my standard email and texting devices.
*This can include written and verbal communications if necessary
Details if necessary
Authorizing Person’s Name:      (Patient, Parent, or Guardian)
Relationship to Patient:

If you are legally authorized representative of the patient, please sign, date and indicate your relationship to the patient. You may be asked to provide documents showing that you are the patient or patient's legally authorized representative

Authorizing Signature:    (Patient, Parent, or Guardian)   Date:   Date

Authorization Expires On:

This consent will expire in 1 year from the date of your signature, unless you indicate an earlier date or event.
Should be Empty:

Patient Information:

I am requesting my medical records be released from:

I am requesting my medical records be released to:

Please check ONE of the following: