Authorization To Release Vision Medical Information

Authorization to Release Vision Medical Information

Please release the records of:

Patient’s Name: ______________________________

Address:

______________________________

Date of Birth: _______________________________

I authorize the release of my vision medical records from:

Eye Doctor’s Name: _______________________________

Address: ____________________________________

____________________________________

To: Webster Eyecare Associates

81 East Main Street

Webster, NY 14580

585-265-3710 - Telephone

585-265-3775 – Fax

Please release all information including the diagnosis and records of any

treatment, examination, or information in your possession concerning me.

Signature _________________________

Date _______________

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Parent category: Legal