Release of Medical Information

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Patient Name *

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Last

Date of Birth *

Day

Month

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Release of Information *

I authorize the release of information to including the Diagnosis, Speaking to the Doctor, Billing and Claim information. This may be release to the following person.

I DO NOT authorize the release to anyone .

This RELEASE OF INFORMATION will remain in effect until terminated by me in writing.

Name *

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Last

Relationship To Patient *

Phone *

Date *

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Month

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Signature of Patient *

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Hart Eye Care

135 GA HIGHWAY 27 E, Americus, GA 31709 »

(229) 928-2024

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Hours

monday:: 8:30 am - 5:30 pm
tuesday:: 8:30 am - 5:30 pm
wednesday:: 8:30 am - 5:30 pm
thursday:: 8:30 am - 6:00 pm
friday:: 8:30 am - 4:00 pm
saturday:: Closed
sunday:: Closed