Medical Records Release

I give my consent to release my medical records to the optometrists at Estrella Mountain Eye Care - Beth Pyle-Smith, OD, and Scott Baker, 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.