Medical Records Release Authorization

Medical Records Release Authorization
Name

First NameLast Name
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select which option applies:

I am authorizing Professional VisionCare to release my vision records to another office/organization.I am authorizing Professional VisionCare to request my medical records from another office/organization.
Releasing Records To:
Requesting Records From:
Please select the method of communication you would like these records to be sent:

FaxMailEmail
Fax Number
Please enter a valid fax number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
If you choose to have your records electronically submitted, there may be some level of risk that the information in the unencrypted email could be read by a third party. PVC is not responsible for any breaches of security. It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon this authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. The recipient may re-disclose the information as he/she chooses, with exception to state or federal laws prohibiting such disclosures.
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

Clear
Date

MonthDayYear
Date
If you are signing as a personal representative of the patient, describe your relationship to the patient and the source ofyour authority to sign this form:
Should be Empty: