RELEASE OF MEDICAL INFORMATION

RELEASE OF MEDICAL INFORMATION

Please complete each section and sign below.
Des Moines Eye Surgeons

PH: 515-225-3546 FAX: 515-224-5946 BACKUP FAX: 515-225-6714
Patient's Legal Name
Maiden Name/Alternate Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Phone Number

Area CodePhone Number
Patient's Email
example@example.com
Name of person and/or institution who will SEND or RELEASE the medical records:
ex: "Des Moines Eye Surgeons" if you are wanting your records sent from us to a different office. For multiple providers/offices, separate with a comma or fill out an additional form.
Phone Number of person and/or institution who will SEND or release the medical records:

Area CodePhone Number
Fax number of person and/or institution who will SEND or release the medical records:

Area CodePhone Number
Name of person and/or institution who will RECEIVE the medical records:
ex: "Des Moines Eye Surgeons" if you are wanting your records sent from a different office to our office.
Phone Number of person and/or institution who will RECEIVE the medical records:

Area CodePhone Number
Fax number of person and/or institution who will RECEIVE the medical records:

Area CodePhone Number
Mailing Address of person and/or institution who will receive the medical records:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I would like this information shared by:

Other
Check the information to be disclosed (include dates below if needed)
Specify records or dates needed (or any additional notes for staff):
Please provide a date by which the info is needed (at least 4 business days unless you call ahead):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please check the reason for release below:
This authorization is voluntary. lf I choose to cancel this consent at a later date, I must send written notification to Des Moines Eye Surgeons. If this consent is cancelled, I understand that information may have been released prior to cancellation, and that action would not be considered a breach of confidentiality. I also acknowledge that: 1) recipients of this information may possibly re-release the information without proper authorization, and 2) once information is disclosed it may no longer be protected by federal privacy regulations. I understand that I may review the disclosed information or ask questions by contacting Des Moines Eye Surgeons.

Completion of this form is not requred as a condition of evaluation or treatment. However, when the requested evaluation or treatment is solely for the purpose of creating a medical report for a third party, if authorization to release the information to that third party is not provided, it may result in the cancellation of those services.
I understand that the information may be released electronically, and may include the following categories unless I specifically deny the release:
Signature of Patient or Legal Guardian (use your mouse to sign or finger)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed name (if not the patient):
Relationship to the patient:
Should be Empty:

RELEASE OF MEDICAL INFORMATION

Des Moines Eye Surgeons