Authorization for Record Release Form

Patient's Name

First Last

As the person whose full name is mentioned hereinabove, I authorize RidgeView Optometry to release the following designated medical information.

Information to be Released

Copy of complete medical records including results of diagnostic testing

Copy of contact lens prescription

Copy of spectacle lens prescription

Insurance information

Other

Release Authorized to

Practice Name or Person Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secure Email

Phone

Fax

I HAVE READ AND UNDERSTOOD THIS FORM. I VOLUNTARILY AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM. IF I AM SIGNING FOR A MINOR CHILD, I ATTEST I HAVE LEGAL AUTHORITY TO MAKE MEDICAL DESIGNATIONS FOR THE DESIGNATED MINOR.

Print Patient Name

First Last

DOB (unless signing for minor)

Patient or legally authorized individual signature

Date

Printed name if signed on behalf of the patient

First Last

Guardian’s DOB (if signing for minor)

Eye Emergency

Authorization for Record Release Form

Release Authorized to

Ridgeview Optometry