Authorization for Release of Medical Records

 

Patient Information:

Name*: 
Date of Birth*: 
Phone Number*: 
Address*: 

Records to be sent to:

Doctor Name/Practice*:
Office Location (address)*:
Office Phone*: 
Office Fax*:
Appointment date (if applicable) 

I hereby grant authorization for the doctors at West Michigan Eyecare Associates to release any and all information from my case records to the above named doctor(s), including glasses and/or contact lens prescriptions, exam findings, and test results.


Patient Signature*:
Date*:
Specials notes/requests:




 I, the requestor for release of medical records, warrant the truthfulness of the information provided in this application.