Medical Record Request Form

Medical Record Request Form
Patient Information

I give permission for Eye Care Specialists to share the information about me that I list in Section I with the person(s) or organization that I list in Section III
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Section I

A. Health and Personal Information. Please describe the information you want Eye Care Specialists to share about you. Please incluType a questionde any dates and details you want to share.
Please provide my medical records for the following dates of service.*

Entire Medical RecordSpecific, please indicate below
Specific, please indicate below
B. Permission about Specific Health Information. Please check off to indicate your permission to release the following information if present in your record

Mental or Psychiatric Health InformationHIV, AIDS, Sexually Transmitted Disease InformationGenetic Testing. See M.G.L. c. 111 § 70GSubstance Use Information
Section II- Reason for Sharing this Information*

Personal RecordsContinuity of CareLegal PurposesOther
Section III - Who May Share This Information and Who May Receive My Information

I give Eye Care Specialists permission to share the information I listed in Section I to:
The person or organization listed in Section I may share the information I listed in Section III with this person(s) or organization:*
Name of person/Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
I understand that the person(s) or organization listed in this section may not be covered by federal or state privacy laws, and that they may be able to further share the information that is given to them.
Delivery Method (there is a fee of $25.00 for medical records requested via paper. There is no charge for records requested electronically)*

MailEmailIn-Person Pickup
Section IV

How Long This Permission Lasts.
This permission to share my information is good until:*

MonthDayYear
Date
- I understand that I can change my ind and cancel this permission at any time. To do this, I need to write a letter to Eye Care Specialists and send it or bring it to the place where I am now giving this permission. If the information has already been given out by, I understand that it is too late for me to change my mind and cancel the permission.
- I understand that I do not have to give permission to share my information with the person(s) or organization I listed in Section III.
- I understand that if I choose not to give this permission or if I cancel my permission, I will still be able to receive any treatment or benefits that I am entitled to, as long as this information is not needed to determine if I am eligible for services or to pay for the services that I receive.
Section V
I, the undersigned, authorize the release of my medical records to the specified individual or entity. I understand that this information may include sensitive and confidential details related to my health.
Full Name*

First NameLast Name
Signature*

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Your Signature Date:*

MonthDayYear
Date
If this form is being filled out by someone who has the legal authority to act for you (such as the parent of a minor child, a court appointed guardian or executor, a custodial parent, or a health care agent),
Full name of person filling out this form:

First NameLast Name
Signature of person filling out this form:

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Describe how this person has legal authority for this individual:
Should be Empty:

Medical Record Request Form

Patient Information

Section I

Section III - Who May Share This Information and Who May Receive My Information

Section IV

Section V

If this form is being filled out by someone who has the legal authority to act for you (such as the parent of a minor child, a court appointed guardian or executor, a custodial parent, or a health care agent),