Medical Records Release

Allied Eye
7405 Shallowford Road, Ste 420 Chattanooga, TN 37421

Phone: 423-855-8522 Fax: 423-855-8533
A copy of this authorization may be utilized with the

Patient Authorization to Release Medical Records
Name of Patient
Date of Birth

MonthDayYear
Date
Social Security #
Return Phone Number
Doctor/Facility to PROVIDE Records
Check if Allied Eye is to Release
Name of doctor/facility
Phone #
Fax #
Address
Doctor/Facility to RECEIVE Records
Check if Allied Eye is to Receive
Name of doctor/facility
Phone #
Fax #
Address
Check box indicating which records you would LIKE sent (one box only)

Most recent office visit (free of charge) Up to one year of medical records ($25 fee) Up to three years of medical records ($50 fee) Each additional year after three years of records ($15 fee)

Initial box/es indicating which records you would NOT LIKE sent

Psychological or psychiatric conditions AIDS/HIV status

Expiration or revocation of authorization: Iunderstand that I may revoke this authorization at any time and that, unless an earlier date is specified, it will automatically expire 12 months after the date below.
Signature of Patient

Clear
Person authorized to sign for Patient

Clear
Date

MonthDayYear
Date
If with Power of Attorney, please attach supporting documentation.
Should be Empty:

Allied Eye