Record Release Form

Medical Record Release

Patient Name*

Today's Date*

Phone*

Date of Birth*

Street Address*

Email*

Information to be release is limited to*

All RecordsSpectacle RXContact Lens RX

Specific record years including or otherwise*

Authorization: I authorize the release of my optometry information as follows (select one)

To:

Address

Fax:

Phone*

Or send to

Texas State Optical Westlake

Fax:512.327.3803

Phone:512.327.3605

Email:tsowestlake@drkamnetz.com

Notice: TSO Westlake and other health organizations are required by law to keep your health informationconfidential. If you authorize your health information disclosure to someone who is not legally required tokeep it confidential, it may no longer be protected by state or federal confidentiality laws.

Your Rights:

Authorization to release health information is voluntary. Treatment, payment, and eligibility for benefits may not be conditioned on signing this Authorization except for the following conditions: 1. To conduct research-related treatment, 2. To obtain information in connection with eligibility or enrollment in a health plan, 3. To determine an entity's obligation to pay a claim, or 4. To create health information to provide to a third party.

This authorization may be revoked at any time. The revocation must be in writing, and signed by you or a patient representative. The revocation will take effect once we receive this, except when others have already relied on it.

You are entitled to a copy of this notice.

Expiration of this notice shall be 12 months past the signing date unless specifically stated otherwise in this notice or by subsequent notice.

Medical Record Release

Patient Name*

Date*

Patient Signature*

Relationship if Representative

By submitting this form I have read and acknowledged the Privacy policy.

Record Release Form

Contact Information

Office Hours

Record Release Form

Contact Information

Office Hours

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