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Medical Record Release — Them to Us
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Medical Record Release
Authorize a previous provider to send your records to Coastal Family Eye Care.
Patient Information
Patient Name
*
Date of Birth
Email
*
Phone
Release Records From
Provider / Organization Name
*
Phone
Address
Records & Purpose
Records Requested
Purpose of Release
I authorize the above provider to release my records to Coastal Family Eye Care. I understand I may revoke this authorization at any time in writing.
Signature
Print Name
Date
Submit Form
