AUTHORIZATION FOR RELEASE

AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION

Date:

Patient Name:

First Last

Patient Address:

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

Patient Date of Birth:

I hereby authorize the release of my medical and/or optical records and request that they be transferred from:

Doctor:

Office:

Address:

Telephone:

Fax:

My personal health information, and complete medical records may be released to the Doctors affiliated with:

ARTISAN OPTICS
(please fax the requested information as noted below)

UPTOWN BOISE
7960 W. RIFLEMAN ST., #150
BOISE, IDAHO 83704
Telephone: 208.377.8899

FAX: 208.321.1952

This records release is valid for 1 year from the date of signing. This records request is for the purpose of continuation of care. Artisan Optics is not liable for any fees associated with the release of the requested information. The patient bears that liability, and requests to be notified in advance of any charges for the release of PHI and/or medical records

The purpose of this release is to obtain:

complete medical / optical records

contact lens prescription

eyeglass prescription

Patient Signature:

Guardian Signature (if patient is a minor):