Records Release Form - From

Patient Request for Access to Patient Health Information

Patient Name (Last, first, middle initial)
Street Address
City
State
Zip
Date of Birth
Day Phone
Evening Phone
Information Released From

Name of Clinic: River Valley Eye Professionals
Facility Address: 2019 Jefferson Road Suite A Northfield, MN 55057
Phone: 507-645-9202
Fax: 507-645-9203

Information Released To
Name of Clinic
Facility Address
Phone
Fax
Information to be disclosed:
Purpose for release of Information:

I give permission to the PROVIDER to release Medical Record Information to the above-named physician, facility, or person. The information released will be restricted by any INFORMATION LIMITATIONS outlined above, and may be used only for the purposes described.

I understand that this release will take effect on the date signed and will be in effect for one year.

I understand that I can cancel this release at any time by notifying the PROVIDER in writing that my cancellation will take effect when the PROVIDER received my written notice. I understand that my cancellation will not have any effect on information released before the PROVIDER received my written notice. Health information used or disclosed may be subject to re-disclosure by the recipient and no longer protected by the privacy rule.

I understand that I am entitled to receive a copy of this authorization.

Patient/Legal Representative Signature
Date
Authority to act on behalf of Patient
Date
Roya1234 none 8:00 a.m. – 5:00 p.m. 9:00 a.m. – 5:00 p.m. 8:00 a.m. – 5:00 p.m. 8:00 a.m. – 5:00 p.m. 8:00 a.m. – 5:00 p.m. Closed Closed optometrist 5076452020