Records Release Form

Records Release Form
Patient's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Date Records Requested*

MonthDayYear
Date
Consent
I, patient undersigned below, authorize:

Carolina Eye Doctors, O.D, PLLC
4350 Main St Suite 107
Harrisburg NC, 28075
Fax 704-230-4100 • Telephone 704-322-3600

to release or obtain my medical information, receipts of payment or balance due, and/or other information considered under the HIPAA privacy law to be part of the Designated Record Set to or from the following contact or entity:
Previous Provider / Office*
Provider / Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Fax (if applicable)
Please enter a valid phone number.
Carolina Eye Doctors and the recipient designated above are released and discharged from any liability, and the undersigned will hold the facility and its doctors harmless for complying with this authorization.
Date*

MonthDayYear
Date
Signature*

Clear
Please type the first 3 letters of your First name and Last name (i.e. JohDoe)*
Should be Empty: