Medical Record Release Form
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Healthcare Provider/Physician/Medical Group Name
First Name
Last Name
Organization Name
Patient Signature
I hereby authorize the release of all records on file related to my health or well-being, which may or may not include protected health information (PHI) and electronic protected health information (ePHI) protected under HIPAA. The purpose of release is transfer of care. I acknowledge that my refusal to sign this authorization will not affect my ability to obtain treatment, nor will it affect my eligibility for benefits. I acknowledge the rights granted to me under HIPAA allow me to revoke this authorization at any time, provided that such revocation is in written format. I acknowledge that any released PHI or ePHI may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I acknowledge this authorization is vald for a period of 90 days. I grant my consent and request the release of the following: All Medical Records Including patient notes, visual fields, images and OCTs To: Eye Consultants of Savannah, Office of Dr. Lily Hipp and Dr. David D. Kim Fax: 912 216 3335 , 4849 Paulsen St.Suite 312 Savannah, GA 31405
I Consent
Submit
Submit
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