Medical Records Release Please note: This form must be completed in full before you can submit it. If there is nothing to list, write “N/A” (not applicable). Date* MM slash DD slash YYYY To:* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Patient Name* First Last Patient Date of Birth* Month Day Year PLEASE RELEASE THE FOLLOWING INFORMATION TO ESTRELLA MOUNTAIN EYE CARE AT THE ADDRESS SHOWN ABOVE IN ORDER TO PROVIDE CONTINUING CARE FOR OUR MUTUAL PATIENT.* Complete Records Optometry Records Visual Field Tests Contact Lens Prescriptions Spectacle Prescriptions Ophthalmology Records Medical Treatment Records Surgical Records X-Rays Ultrasounds Biopsy Results Other If other, please specify:* Your name* Name of person to whom you are giving your consent* I give my consent to release my medical records to the optometrists at Estrella Mountain Eye Care - Beth Pyle-Smith, OD. I understand that my medical records are confidential. I understand that by signing this consent form I am allowing my medical information to be released upon my doctor's request to Estrella Mountain Eye Care for the purpose of health care treatment, management and business operations. I also understand that I may revoke this consent by written request at any time. If revoked, it is understood by all parties that all information released prior to being notified of such revocation was made with my consent. I understand that I have the right to restrict the disclosure of specific information in my medical records if I request such restriction in writing. I also understand that my request for restriction may be denied if the information restricted is required for health care operations. I have read the above and foregoing consent for release of medical information. I hereby acknowledge that I am familiar with and fully understand the terms and conditions of this consent.Signature*Date* MM slash DD slash YYYY