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My Vision Connection LLC

Digital Records Release Request Form

We are committed to protecting your privacy and ensuring the confidentiality of your medical records. Please complete the form below to request the release of your digital medical records. All fields marked with an asterisk (*) are required.

Patient Information
Address ( Required)
Release Information
Recipient Information (if applicable)
Authorization and Consent
I hereby authorize to release my digital medical records as specified above. I understand that:
  1. This authorization is voluntary.
  2. I have the right to revoke this authorization at any time, except where action has already been taken.
  3. I have the right to inspect or copy the information to be disclosed, as provided by applicable law.
  4. There may be a fee associated with the release of records.

Privacy Notice: We are committed to protecting your privacy. The information you provide will be used solely for the purpose of fulfilling your records request and will not be shared with third parties except as required by law.

Contact Information: For questions regarding this form or your request, please contact our office at 754-313-4137.

My Vision Connection LLC

100 S Military Trail #13 Deerfield Beach FL 33442

754-313-4137

Luigi@2020advancedeyecare.com

www.2020advancedeyecare.com

Feel free to modify the fields and information to better suit your needs. Ensure that the form complies with all applicable laws and regulations regarding the release of medical records, such as HIPAA in the United States.