Clone of Release Records To ECNC

AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION
Patient Name*

First NameLast Name
Previous Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
RELEASE RECORDS TO:

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

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax
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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

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Date Signed

MonthDayYear
Date
Parent/Guardian Signature

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Date Signed

MonthDayYear
Date
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AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATION

OBTAIN RECORDS FROM: