Medical Records Release Form

Medical Records Release Form (all Clarus Eye Centre locations)
Patient Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Guardian or Authorized Party Name (if applicable)

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Information Requested
Records relating to treatment from Date to Date
Records for ALL eye care at this facility by:

Grant Aaker, M.D. (Cataracts, Comprehensive)Anthony Grillo, M.D. (Cataracts, Refractive, Cornea)Jane Myung, M.D. (Retina)Blake Perry, M.D. (Oculoplastics)Penny Reck, M.D. (Retina)Stephen Reck, M.D. (Cataracts, Glaucoma)Corinne Bacher, O.D. (Optometry)Tammy Burrell, O.D. (Optometry)Kristen Clark, O.D. (Optometry)Jacquelin Escoto, O.D. (Optometry)Chong Lee, O.D. (Optometry)Michelle Lee, O.D. (Optometry)Janat Mathew, O.D. (Optometry)
Other (please specify):
Information to be released:*

TOFROM
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Additional Information or Fax # for Delivery:
Information to be released:*

TOFROM
CLARUS EYE CENTRE (MAIN)

345 COLLEGE STREET SE, SUITE C

LACEY, WA 98503

PH: 360-456-3200

FAX: 360-456-3894
Confirmation of Medical Records Release:
- I understand that I have the right to revoke this authorization, in writing, at any time, except:
  1. where uses or disclosures have already been made based upon my original permission or
  2. the authorization was obtained as a condition of securing insurance coverage and the insurer by law has the right to contest a claim or the insurance policy.
- I understand that uses and disclosures made based on my original permission cannot be taken back.
- To revoke this authorization, I must do so in writing, and without my express consent will automatically expire in 90 days from this date.
- I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and no longer protected by the federal Privacy Standards.
- I understand that Clarus Eye Centre may not condition treatment on my signing this authorization and that I have a right to refuse to sign this authorization.
Signature of Patient or Guardian *

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Date*
***An electronically submitted, faxed, or photocopy of this consent shall be valid as the original.***
If my medical records include information regarding drug abuse, alcoholism or alcohol abuse, or psychological/ psychiatric conditions, I DO I DO NOTauthorize the release of this information.

If an individual’s representative signs this authorization, the representative’s authority is based on: (e.g., state law, court order, etc.)
FEE SCHEDULE: State and federal laws specify a reasonable fee may be charged to offset the cost associated with the reproduction of records. No fee shall be charged for reproducing and forwarding records directly to other physicians.

SUBMISSION: Hitting the 'SUBMIT' button at the end of this form automatically delivers a HIPPA-compliant copy to our secure internal email address, medicalrecords@claruseye.com.

For a printable version of this form, please CLICK HERE. Complete and return physical forms via mail, fax, or physical drop-off to:

Clarus Eye Centre

345 College Street SE, Suite C

Lacey, WA 98503

PH: 360-456-3200

FAX: 360-456-3894
***For all submissions, please allow up to 10 business days for request fulfillment. We will contact you with any questions. Thank you!***
Should be Empty:

Medical Records Release Form (all Clarus Eye Centre locations)

Information Requested