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Maryland Medical Records Release Form 2

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This form is provided by Specialized Eye Care to authorize the disclosure or release of one person's protected health information.

Maryland Medical Records Release Form 2
Maryland Medical Records Release Form 2
SPECIALIZED EYE CARE (located in the Village of Cross Keys)
1 Village Square, Suite 190 Baltimore, Maryland 21210 | Phone: 410-435-8881 | Fax: 410-435-8886 | Website: www.specializedeyecare.com
MEDICAL RECORDS RELEASE AUTHORIZATION FORM
PATIENT NAME __________________________________________________________________________
ADDRESS ______________________________________________________________________________
TELEPHONE # __________________________________________________________________________
SSN _____________________________________ DOB _______________________________________
I authorize the custodian of the records of __________________________________________________________
!!!!!!!! (Practice name and address)
____________________________________________________________________________________________
to release the following information (Please check all that apply)
These records are for services provided on the following dates: _________________________________________
Please send the records listed above to:
Name ______________________________________________________________________________________
Address ____________________________________________________________________________________
Phone ________________________________________ Fax _________________________________________
This authorization shall expire no later than ! __________________ and may not be valid for greater than one
year from the date of signature for Maryland medical records.
Signature of Patient or Representative!! ! ! ! ! ! ! ! ! Date
Printed Name of Patient or Representative! ! ! ! If Representative, Relationship to Patient
All Records
Consultation Notes
Operative Reports
Laboratory/Pathology
Progress Notes
Admission Notes
MEDICAL RECORDS RELEASE
AUTHORIZATION FORM | Page 1 of 1
Maryland Medical Records Release Form 2