Authorization for Release of Information

Name: Advanced Family Eyecare
Address: 14000 Quailbrook Drive, Oklahoma City, OK, 73134, US
Telephone: 405-751-7727
Price range: $000 - $300

I hereby request the disclosure of information from my record.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
DOB
MM slash DD slash YYYY
The information is to be released TO/FROM
Name/Agency
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
FAX
Email
Contact Person(s)
The information is to be released by mail, phone, email, or fax TO/FROM:

Advanced Family Eyecare
14000 Quailbrook Dr.
Oklahoma City, OK 73134
(405) 751-7727/ fax (405) 755-1875
The information to be released is as follows
- Any information contained in the patient’s record
- Only information related to the patient’s educational success
Specify
- I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate one year from the date authorized.
- I understand that the recipient of the disclosed protected health information may not have any legal obligation to maintain the further confidentiality of the protected health information.
- We cannot refuse to treat you if you choose not to sign this form.
- Signature
  (Patient, Parent, or Legal Guardian)
- Date
  MM slash DD slash YYYY