Medical Record Release Request Form from Eyes of East sac to another office

Records Release Request

From Eyes of East sac to Another office
Patient Name***

First NameLast Name
Date of Birth*

MonthDayYear
I would like my records transferred from: Eyes of East Sacramento

3315 Folsom Blvd

Sacramento, CA 95816

ph: 916-246-8111

fax: 888-965-3518
I would like my records (or minor I'm responsible for) transferred to:*
Office Name
Doctor's Name

First NameLast Name
Office Phone Number*

Area CodePhone Number
Office Email
example@example.com
Office Fax Number

Area CodeFax Number
I, First Name Last Name , authorize Eyes of East Sacramento to release all vision medical records relevant to eyecare treatment, or copies of such and request that they be transferred to Office named above for patient named above** .
Signature of Responsible Party*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Records Release Request