Transfer of Information
Zen Eye Care P: 218-522-4645 F: 218-481-7811
Name
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First Name
Middle Name
Last Name
Date of Birth
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Month
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Day
Year
Date Picker Icon
I authorize the following eye care practitioner to release information to Zen Eye Care:
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Please release all Optometric records from:
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The last exam
The last year
Other
Purpose of Disclosure:
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Continuing care
Other
Acknowledgement of Understanding: I understand the expiration date of this authorization is 1 year. I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extend action has already been taken. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal privacy regulations. I understand by authorizing this use or disclosure of information, there will be no conditions placed on my healthcare or payment for my health care. I understand I may request a copy of this form after I have signed it. I understand that in compliance with MN Statue 144.33 and WI Administrative Code HHS117, I may be required to pay a fee for retrieval and photocopying of records and/or supervising inspection of medical records.
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I have read the Acknowledgement and Understanding section
Signature
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