Medical Record Release Form
Patient Information
Patient Name
First Name
Last Name
Parent Name if Patient is a Minor
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to Release Information
HealthCare Provider/Physician/Medicare Contractor Name
Title
First Name
Last Name
Organization Name
Phone Number
Format: (000) 000-0000.
Fax Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to Receive Information
Eyes of East Sacramento
3315 Folsom Blvd
Sacramento , CA 95816
916-246-8111
fax 888-965-3518
Release Details
I, the patient, authorize and request the disclosure of all protected information I select below full and complete.
All medical records with every page included.
Last Exam: including most recent tests (OCT, VF, Pach, etc.)
Contact Lens Prescription
Records from time period_______________to ____________________
What is the purpose of the disclosure:
Changing providers
Permanent Transfer of care
Seeking Second opinion
Personal Use
I, the patient, agree with the following statements:
I authorize the disclosure of such health information as described herein. I understand that treatment is not conditioned upon the execution of this authorization.
I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by those regulations.
I understand that Eyes of East Sacramento may charge a fee for the cost of copying, mailing or other supplies and services associated with this request. I understand that Eyes of East Sac may use a business associate for copying requested medical records as described in the Notice of Privacy Practices .
I understand that I may revoke this authorization at any time by providing a written notice to the person identified below except to the extent that action has been taken in reliance upon it or except otherwise stated in Eyes of East Sacramento's Notice of Privacy Practices by mailing or hand delivering written notification to the following person: Privacy Officer 3315 Folsom Blvd Sacramento , CA 95816
I understand that Eyes of East Sacramento is not responsible for completeness, legibility, or omitance caused by the copying of any medical records from another institution.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: