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