Medical Records Release Form

By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical record, or a summary of a narrative of my health information, to corridor Family Eyecare listed below:

Corridor Family Eyecare
5350 Blvd. Ste. 100
Cedar Rapids, IA 52404
319-365-2946 Office
319-365-2948 Fax
www.CorridorFamilyEyecare.com

Other ( please specify below)

HIV/AIDS: I consent to the release of any positive or negative test result for AIDS or HIV antibodies to AIDS, or infection with any other causative agent of AIDS with the rest of my medical records.

Date

Release my protected health information to the following: Corridor Family Eyecare.

The purpose/reason for this release of information is as follows:

Name of Medical Office

Address of Medical Office

Phone Number of Medical Office

I understand that Corridor Family Eyecare will provide this information within 15 days from the receipt of request and that a fee for preparing and furnishing this information may be charged according to rules set forth by the Iowa State Board of Medical Examiners.

Signature of Patient or Personal Representative

Type your full name for your digital signature

Patient Name

First Name

Last Name

Name of Personal Representative

First Name

Last Name

Description of Personal Representative's Authority

Patient Date of Birth or Social Security Number

Date

Your information will be encrypted.