Medical Record Release Form

Please fill out this form to allow us to request records from other doctors, or to release your records from Capital Eye Care

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Patient Name *

Date of Birth *

I authorize the use and disclosure of my health information for following time period:

All Records

From

Information to be released between the following parties: *

From Champlain Ophthalmology
To Champlain Ophthalmology

Provide name and full address of the other party.

Address

Phone

Fax

Form in which records are to be released: *

Disclosure:

I understand that I have the right to revoke this authorization, in writing, at any time, except (1) where uses or disclosures have already been made upon my original permission or (2) the authorization was obtained as a condition of securing insurance coverage. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that the medical records to be released may contain information related to HIV status, AIDS, Sexually Transmitted Diseases, alcohol, or mental health services, and I hereby authorize the release of the information. To revoke this authorization, I must do so in writing and without my express revocation; this consent will automatically expire in a year from today’s date. I understand that it is possible that information used or disclosed with my permission may be redisclosed by the recipient and no longer protected by the federal Privacy Standards.

FEE SCHEDULE:

State and federal laws specify a reasonable fee may be charged to offset the cost associated with the reproducing and forwarding of medical records. Black and White copies of last 4 visits free, if more is necessary, a preparation fee of $22.88, plus $0.76 per page, plus postage will be charged. I understand that Capital Eye Care, LLC, Champlain Ophthalmology may not condition treatment on my signing this authorization and that I have a right to refuse to sign this authorization.

If this authorization is submitted by a patient’s personal representative, the representative authority is based on:

Guardian or Authorized Party Name (if other than the patient)

By checking this box, I am confirming that I am authorized to request these records. *

I Agree