Please Complete This Form in Its Entirety

Dr. Robert W. Johnson, MD
Diplomate American
Board of Ophthalmology
/ AUTHORIZATION TO RELEASE COPIES OF A MEDICAL RECORD / FOR CLINIC USE ONLY:
r  Records sent from Clinic – please image form to patient record
r  Mailed
r  Picked Up
r  Faxed
Date Received: ______
Date Processed: ______
Processed By: ______

Please complete this form in its entirety.

Patient Name: ______Maiden/AKA: ______Date of Birth: _____/_____/______
Street Address: ______City/State/Zip: ______Phone: ______

Purpose of Disclosure:

Island Eye Care • 231 SE Barrington Dr. Suite 208 • Oak Harbor • WA • 98277• Freeland Office – 1804 Scott Rd. Suite 106 • Freeland• WA • 98249

Phone: (360) 240-2020 • Fax: (360) 240-1989

r  Personal

r  Transfer of Eye Care

r  Provider

r  Insurance

r  Other (specify – moving, workers comp, e.g.)______

Island Eye Care • 231 SE Barrington Dr. Suite 208 • Oak Harbor • WA • 98277• Freeland Office – 1804 Scott Rd. Suite 106 • Freeland• WA • 98249

Phone: (360) 240-2020 • Fax: (360) 240-1989

I authorize ______to release the following health care information:

¨  Summary of Visit/Chart notes from date: ______to date: ______

¨  All Medical Records (diagnostic tests included) from date: ______to date: ______

¨  All health care information in my medical record

¨  Health care information in my record relating to the following treatment or conditions: ______

¨  Diagnostic Tests (specify type – images, x-rays, e.g.) ______

¨  Other (specify type – operative reports, bills, lab reports, e.g.) ______

Health Care Information to be released to:

Island Eye Care

231 SE Barrington Dr. Suite 208

Oak Harbor, WA 98277

P. (360) 240-2020

F. (360) 240-1989

Select delivery method:

Island Eye Care • 231 SE Barrington Dr. Suite 208 • Oak Harbor • WA • 98277• Freeland Office – 1804 Scott Rd. Suite 106 • Freeland• WA • 98249

Phone: (360) 240-2020 • Fax: (360) 240-1989

r  Fax (health providers only)

Island Eye Care • 231 SE Barrington Dr. Suite 208 • Oak Harbor • WA • 98277• Freeland Office – 1804 Scott Rd. Suite 106 • Freeland• WA • 98249

Phone: (360) 240-2020 • Fax: (360) 240-1989

r  US Mail

r  I will personally pick my records up (payment will be required at pick up)

This authorization expires on: ______(specify expiration date or event)
Note: Authorizations to disclose your information can only be effective for a maximum of 90 days from the date signed by you.

I hereby authorize disclosure of the health information for the above named patient. I understand that I may revoke this request with written notification, but that it will not effect any information released prior to notification of cancellation. I understand that information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal regulations. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me whether or not I sign the authorization.
I have read this Authorization, or had it explained to me, and I understand its contents.

______ _____/_____/______

Signature of Patient or Legally Authorized Representative: Date: (mm/dd/yyyy)

______

Printed name of Patient or Legally Authorized Representative (if patient is a minor or unable to sign) Relationship to Patient:

Island Eye Care • 231 SE Barrington Dr. Suite 208 • Oak Harbor • WA • 98277• Freeland Office – 1804 Scott Rd. Suite 106 • Freeland• WA • 98249

Phone: (360) 240-2020 • Fax: (360) 240-1989

Island Eye Care • 231 SE Barrington Dr. Suite 208 • Oak Harbor • WA • 98277• Freeland Office – 1804 Scott Rd. Suite 106 • Freeland• WA • 98249

Phone: (360) 240-2020 • Fax: (360) 240-1989