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Cornea and contact lens institute of minnesota

Cornea and contact lens institute of minnesota 2025

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The document is a Medical Records Release Form that authorizes the Cornea and Contact Lens Institute of Minnesota to release or obtain medical information regarding a patient. It includes sections for patient identification, authorization details, types of records requested, and a signature line for the patient or authorized representative.

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Click ‘Get Form’ to open the Medical Records Release Form in the editor.
Begin by entering the Patient Name, Address, City, State/Zip, Date of Birth, and Phone number in the designated fields. Ensure all information is accurate for a smooth processing experience.
In the authorization section, clearly indicate your choice by checking either or both boxes for releasing or obtaining information. Fill in the Name/Title, Street Address, Organization, City, Fax Number, State, Zip, and Phone Number of the recipient.
Select the records you wish to request by checking the appropriate boxes under 'Records Requested'. Options include Eye/vision exam records and Psycho educational reports among others.
Finally, print your name as the Patient or Authorized Representative. Enter the date and provide your signature along with your relationship to the patient to complete the form.

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