Authorization For Release Of Medical Information


Patient Information

Patient First Name
Patient Last Name
Patient Middle Initial
Patient Gender
Patient Date of Birth
Phone Number
Social Security Number (last 4 only)
Address Line 1
Address Line 2
City
State
Zip Code
Email Address
Source of Records (optional)

 

I, the undersigned, request and authorize Center For Sight PC, the above-named doctor or practice, and my other medical providers to release medical information of the patient named herein to Dr. Christopher O’Brien MD and Bright Eye Consultants PC, Fax 865.262.8550, 6311 Kingston Pike, Suite 6W, Knoxville, TN 37919.  The purpose of this release is ongoing patient care with Dr. Christopher O’Brien MD.

Please transmit at least the 2 most recent patient exams, operative reports, and the results from any auxiliary testing, such as visual field testing, OCT, and IOL Master.

I understand that: 
* I may refuse to sign this authorization.
* Refusing to sign this authorization will not affect my treatment, payment, enrollment, or eligibility for benefits. 
* I may take back (revoke) this authorization in writing, except for any actions already taken based upon it.
* I understand that this authorization will expire when the records are released for the request dated below. Any requests after this date will need a separate authorization.
* I may request a copy of this form after I sign it. 

I, the undersigned, attest that I am legally authorized to make healthcare decisions for the above patient.  I have read and understand the above release authorization.

Sign Here:

Full Legal Name Of Signer: 
Signer's Relationship To Patient: , if "Other" please explain: 
 

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