• AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION

  •  - -
  • RELEASE RECORDS TO:

    Denver Eye Surgeons
    13772 Denver West Parkway
    Building 55, Suite 100
    Lakewood, CO 80401
    303-376-4075 Phone
    303-279-9140 Fax

     

  • OBTAIN RECORDS FROM:

  • We are requesting the most recent two years of records unless otherwise specified.

  • I hereby authorize the Denver Eye Surgeons 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 Denver Eye Surgeons 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.

  • Clear
  •  - -
  • Clear
  •  - -
  • Reload
  • Should be Empty: