Guardian-Parent Release Form

Authorization of Release Information

Patient Name:

Date of Birth

I authorize Vision Park Family Eye Care to release my medical information to:

Name:

Relationship:

Phone:

Fax:

The Disclosure is for the following purpose(s):

Medical RecordsBilling and InsurancePrescriptionOther

The release expires on

or one year from the date signed.

I understand that I may refuse to sign this authorization or revoke this authorization at any time. I understand that my revocation or refusal to sign this authorization will not affect my ability to obtain health care services unless the services are at the request of the party to whom the protected health information will be disclosed. I also understand that if I revoke, the information described above may be re-disclosed and will no longer be protected by the regulations.

Parent Signature or Patient's Legal Representative

Date:

Printed name of patient's legal representative:

Relationship to the patient:

Thank You!

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