Progressive Vision Institute — Referring Optometrists : Medical Records Release

Sender's Information

Sender Name

Sender Email

Patient Information

Patient Name

Birth Date (00/00/0000)

Address

City

State

Zip

Physicians Information

Authorizes

Name of Physician - Releases

Address

City

State

Zip

Release of Records to

Name of Physician - Releases

Address

City

State

Zip

Information to be Released

All Clinic Records
Eye Records
Office Notes
Photographs

Visual Fields
X-Ray Reports
Immunization Records
X-Ray Films (Specify)

Visual Fields
Lab Reports
Electrocardiograms
Other (Specify)

X-Ray Films Specified

Other Specified

List other facilities records to be included when releasing for the purpose of continuing medical care:

For the following dates:

In compliance with state statutes which require special permission to release otherwise privileged information,
please release records pertaining to:

Mental Health
Developmental Disabilities
Alcoholism

AIDS Test Results
AIDS-related Disease Diagnosis

Drug Abuse
Other

Other Specified

Purpose or need for disclosures: (check applicable categories)

Further Medical Care
Application for Insurance
Disability Determination

Payment of Insurance Claim
Vocational Rehabilitation Evaluation

Legal Investigation
Personal
Other (specify)

Other Specified

I understand that this authorization shall be valid for one (1) year unless otherwise stated below
or revoked through written notice to Medical Records

Alternate Date if not one (1) year

I authorize the release of my medical records in accordance with the specifications listed above.
I understand written notice is necessary to cancel this request

Signature of Patient Date of Signature

Authorized Signature Relationship

Patient is:
Minor
Incompetent
Disabled

Legal Authority:
Legal
Legal Guardian
Next of Kin of Deceased

Security

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Referring Optometrists: Medical Records Release