Clone of Release Records From ECNC

AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION
Patient Name

First NameLast Name
Previous Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
OBTAIN RECORDS FROM:

Boulder Eye Surgeons
4745 Arapahoe Ave STE 100
Boulder, CO 80303
303-444-3000 Phone
303-444-3226 Fax
RELEASE RECORDS TO:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
We are requesting the most recent two years of records unless otherwise specified.
Comments
I hereby authorize Boulder Eye Surgeons to obtain the specified information as stated in this authorization. I understand that the information in my health record may include information relating to sexually transmitted diseases, HIV/AIDS, mental health and drug or alcohol abuse. We will not include records from other doctors’ offices. I hereby release Boulder Eye Surgeons and its employees from any and all liability that may arise from the release of information as I have directed. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Without my express revocation, the authorization will automatically expire one year from the date of signature.
Patient Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
Should be Empty:

AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION

RELEASE RECORDS TO: