Records Release Form

Patient Name (Last, first, middle initial)

Street Address

City

State

Zip

Date of Birth

Day Phone

Evening Phone

Information Released To

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 From

Name of Clinic

Facility Address

Phone

Fax

Purpose for release of Information:

Treatment and related usesOther (explain)

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