Medical Records Release

Please fill out all information below, and click SUBMIT to send us your medical records release.

Please click here to download a paper form. You may fax the completed form to your preferred office location.

Authorization for Release of Medical Records Information

Please Select One

I am requesting my entire medical record. I understand that I will be charged a 25.00 dollar fee.

I am requesting the last exam notes only, which will be provided to me at no cost.

Patient Information

Full Name (please print)

Date of Birth

Address

City

State

ZIP

Telephone

Fax

I hereby authorize Tallman Eye Associates to release the medical records of the above-named person

Are you leaving our practice?

Yes

Signature of this document will verify that:

I understand that treatment and coverage is based upon my signing this authorization. The information is needed for the following purpose: (select one)

To provide ongoing treatment/aftercare

At the request of the patient (or parent, or legal guardian)

Other

Patient / Parent or Guardian Signature:

Date:

Relationship to Patient:

*Disclaimer* I understand this serves as an official signature

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.