Records Release Form - To

Patient Request for Access to Patient Health Information

Patient Name (Last, first, middle initial)
Street Address
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
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
Authority to act on behalf of Patient
ep246 none 8:00 a.m. – 5:00 p.m. 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. Closed Closed optometrist 5076452020 Enable