Release Records From Cheyenne Eye Clinic & Surgery Center

AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION
Patient Name*

First NameLast Name
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Date of Birth*

MonthDayYear
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RELEASE RECORDS FROM:

Cheyenne Eye Clinic & Surgery Center

1300 E. 20th St.

Cheyenne, WY 82001

Phone: (307) 634-2020

Fax: (307) 635-6510
RELEASE RECORDS TO:
Name*

First NameLast Name
Address*

Street Address

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Postal / Zip Code
Phone Number*
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Fax
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We are requesting the most recent two years of records unless otherwise specified.
Comments
I hereby authorize the Cheyenne Eye Clinic & Surgery Center to obtain the specified information as stated in this authorization. I understand that the information in my health record may include information relating to sexually transmitted diseases, HIV/AIDS, mental health and drug or alcohol abuse. We will not include records from other doctors’ offices. I hereby release the Cheyenne Eye Clinic & Surgery Center and its employees from any and all liability that may arise from the release of information as I have directed. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Without my express revocation, the authorization will automatically expire one year from the date of signature.
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AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION

RELEASE RECORDS TO: