• MEDICAL RECORDS RELEASE (All sections must be completed)
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  • I authorize the disclosure of the Protected Health Information for the above-named patient as described:

    Information Requested:
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • University Eye Specialists 1932 Alcoa Highway, Suite 255 Knoxville, TN 37920 Phone: 865-244-2020 Fax: 865-342-3494
  • I understand I have a right to revoke this authorization by written notification to the Privacy Officer, except to the extent it has acted in reliance thereon before notice of revocation. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure which may not be protected by federal confidentiality rules. I understand that I may request a copy of this authorization. I understand that I can refuse to sign this authorization and the above-named office may not condition treatment on my signing of this authorization.
  • Type your complete name here. Please note that full social security must be present on above form to process this request.
  • Date Format: MM slash DD slash YYYY
  • ** For personal copies of medical records, the first twenty-five (25) pages are provided at no charge. If your chart is more than twenty-five (25) pages, our office will contact you by phone to notify you of the fee.