Medical Records Release Form

I grant permission to release a copy of my medical records to SAMUELSON EYECARE.

In initiating this request, I hereby release my practitioner from any laws governing the disclosure of confidential or privileged information.

Please enter all of the necessary information below and click “Submit”:

Patient Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Date of Request*
MM slash DD slash YYYY
Address*
Name of office where previous eye exam was held.

Clinic/Office Name Street Address City State ZIP Code
Disclosure Period, From Date to Present Date*
MM slash DD slash YYYY
Digital Signature of Patient or Patient's Representative*
Comments
This field is for validation purposes and should be left unchanged.