Records Release Form

Patient:

DOB:

Address:

City:

State:

Zip:

Date Records Requested:

Date Records Received:

First Eye Care

Dr. Craig C Hughes

Therapeutic Optometrists

Dr. Blake J. Hughes

751 Mid Cities Blvd Hurst, TX 76054

Dr. Richelle Bean

Telephone: (817) 656-2020

Dr. Viren Choksi

Fax: (817) 656-5908

Release toObtain medical records from the following:

Doctor:

Address:

Telephone:

Fax:

Instructions:

(Please include inclusive dates and/or specific type of records)

This facility and its doctors are hereby released and discharged from any liability, and the undersigned individual will hold the facility and its doctors harmless from complying with this authorization.

Patient Signature

Date

Relationship:

*Notice to person or agency receiving this information: this information has been disclosed to you from records whose confidentiality is protected. Statues and regulations prohibit you from making further disclosure of it with the specific written consent of the person to whom it pertains OR as otherwise permitting by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.

Records Release Form

First Eye Care

Hurst

Keller

Roanoke

Our Locations

Hurst

Keller

Roanoke

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Records Release Form

First Eye Care