Incoming Records Release AUTHORIZATION TO RELEASE HEALTHCARE INFORMATIONPatient’s Name First Last Date of Birth MM slash DD slash YYYY Previous Name (if applicable): I request and authorize to release healthcare information of the patient named above to: Cary Family Eye Care 10110 Green Level Church Road Suite 102 Cary, NC 27519 Telephone: 919-465-7400 Fax: 919-465-7455 To release healthcare information of the patient named above to:This request and authorization applies to: Healthcare information related to the following treatment, condition, or dates: This request and authorization applies to: All healthcare information Other Other Patient/Guardian Signature:Date MM slash DD slash YYYY Name (print)
