AUTHORIZATION TO RELEASE RECORDS

Patient’s Name:

First Last

Date of Birth:

Previous Name:

First Last

Phone Number:

I request and authorize BASS LAKE FAMILY EYE CARE to release the records of the patient named above to:

Clinic/Office Name

Address

Street Address City State / Province / Region ZIP / Postal Code

This request and authorization applies to:

Records relating to the following treatment, condition, or dates:

All records

Other:

Untitled

CONTACT FOR NEW OFFICE:

FAX NUMBER:

PHONE NUMBER:

Patient Signature:

Date Signed:

Bass Lake Family Eye Care