Medical Records Release

Atlee Gleaton EyeCare

227 Eastern Avenue

Augusta, Maine 04330

Phone:(207) 622-3185

Fax: (207) 622-5697

MEDICAL RECORDS RELEASE AUTHORIZATION

Patient Name: ______________________________

Date of Birth: ____________________________

I authorize Atlee Gleaton Eye Care to:

◊  Release my health information to: ___________________________________________

◊  Receive my health information from:

Practice or Doctor’s Name: __________________________________________________

Address: _________________________________________________________________

Please specify applicable dates of service: _______________________________________

Please specify information to be released:

◊ Office notes/treatment

◊  Operative report

◊  Contact lens records

◊  Specialty testing (visual fields, OCT, HRT, GDx, photos, Fluorescein angiography)

◊  Other: ______________________________________________________________

This authorization is effective until: ________________(date not to exceed one (1) year).

Signature of Patient or Authorized Representative: ____________________________________

Relationship: _______________________________

Date: ______________________________________