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Records Release Form

Patient Name

I authorize the use and/or disclosure of my protected health information as described below.

**I am authorizing Kibo Eyecare of Glastonbury to release the following records on my behalf ***

Most recent eye examOffice notes pertaining toMost recent eye testEntire Medical RecordOther

The reason for this release is because

I am changing physiciansFor coordination of care with my other doctorI am moving and not sure of a new physician would just like a copy for my records

Give the requested information to:(Check one)

MeIndividual Named Below

Address

This authorization will expire 180 days from the date signed. I can revoke this authorization anytime in writing, however if the requested information has been already disclosed I realize it cannot be taken back. I have reviewed and I understand this authorization. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected under federal law. I also understand there may be fees of $0.65 per page per copy and for postage.

Records Release Form

Patient Name

I am authorizing Kibo Eyecare of Glastonbury to release the following records on my behalf *​​​​​​​

The reason for this release is because​​​​​​​

Give the requested information to:(Check one)​​​​​​​

Address

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**I am authorizing Kibo Eyecare of Glastonbury to release the following records on my behalf ***

The reason for this release is because

Give the requested information to:(Check one)