Authorization For Release Of Medical Record Information Form printable pdf download

Authorization For Release Of Medical Record Information Form

Hearne Vision Care

29 East Poplar Street

North Vernon. IN 47265

Phone: 812-346-4646 Fax: 812-352-6262 Email:

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION

Name:________________________________________________________________________________________

Tel. No. _______________________________________ Date of Birth: _______________________________

Street Address: ____________________________________________________________________________

City: ___________________________________ State: __________________ Zip Code: ________________

The specific information that I wish to have released is:

¨ All Clinical Medical Records

¨ Other Records-Please list or circle (e.g. billing photographs OCT GDx visual fields):

_________________________________________________________________________________________

¨ Other records: (only last exam and glasses and/or contact lens prescription information, limited data)

This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually

transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this

information can be released.

¨ I consent to have the above information released.

¨ I do not consent to have the above information released.

Signature: _____________________________________________________________Date: ___________________

(Parent or Legal Guardian of a Minor)

This medical record may contain information concerning HIV testing and /AIDS diagnosis or treatment.

Separate consent must be given to have this information released.

¨ I consent to have the above information released.

¨ I do not consent to have the above information released.

Signature: _____________________________________________________________Date: ___________________

(Parent or Legal Guardian of a Minor)

I understand that this authorization is valid for a 360-day period from the date that is signed. I may

revoke this consent at any time through written notice.

Release Records To:

Hearne Vision Care

Dr. Kirk Hearne

29 E. Poplar Street

North Vernon, IN 47265

Phone: (812) 346-4646 Fax: (812) 352-6262 Email:

Authorization For Release Of Medical Record Information Form