Request of Medical Records

Name*

First Middle Initial Last

Birth Date*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

At my request, I authorize:

Practice name:*

Doctor:*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax*

TO MAKE DISCLOSURE TO:

OWEN EYE CARE 620 E FIRST ST., NEWBERG, OREGON 97132 PHONE: (503) 847-9183 FAX: (971) 832-8578

Specifically, I authorize the use of the following information:*

Complete records
VT notes
Chart notes
Diagnostic notes

Specific Dates*

From:

Specific Dates*

To:

Statement of Understanding:

Information used or disclosed to this authorization may be subject to redisclosure by the recipient and no longer protected by federal law.

I understand and acknowledge that this authorization extends to use and/or disclosure from my medical records which may include treatment for physical and mental illness, alcohol and/or drug abuse, and/or Aids, and/or may include results of an HIV test or the fact that an HIV test was performed.

You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment or payment or your eligibility for benefits.

This authorization is valid for 180 days unless otherwise revoked by written notice. This does not apply to information already used or disclosed in response to this authorization.

You may inspect or copy the protected health information to be disclosed or used under this authorization.

Signature of Patient / Patient Representative:*

Date*

Relationship to Patient:*