Authorization for Release of Medical and/or Ophthalmic Records Please complete the following information: Patient 's Name Date of Birth Address City, State, Zip I request and authorize to release all Medical and/or Ophthalmic records of the 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient's Name in the designated field. Ensure that you spell the name correctly for accurate record-keeping.
3. Next, input the Date of Birth. This is crucial for identifying the correct medical records associated with the patient.
4. Fill in the Address, including street, city, state, and zip code. This information helps in verifying the patient's identity.
5. In the section requesting authorization, specify who is authorized to release the records. For example, write 'English Rows Eye Care' as indicated.
6. Review and check all items listed under what is included in this request. Make sure all necessary documents are covered.
7. Sign and date at the bottom of the form to validate your authorization. If someone else is signing on behalf of the patient, complete their information as a guardian or representative.

Start using our platform today to easily fill out your Authorization for Release of Medical and/or Ophthalmic Records for free!