Patient Records Request2018-08-15T09:18:08+00:00

Patient Records Request

  • The following health information that relates to all services rendered at Brinton Vision may be released:

    • Entire Medical Record including patient histories, office notes, test results, referrals, consults, and records sent by other healthcare providers.
    • Patient History
    • Office Notes
    • Test Results
    • Referrals
    • Consults
    • Records Sent by Other Health Care Providers
  • Patient Information

  • Where Records are to be sent to:

  • I have read (or have had read to me) this authorization, and I agree to its terms as indicated by submitting this form. I acknowledge that I will need to allow up to 30 days for records transfer (but we will typically send your records within 7 days). The information contained in this Release of Medical Records is privileged and confidential information intended only for the review and use of the individual entity named above. If the reader of these records is not the intended recipient, you are hereby notified that any disclosure, dissemination, distribution or copying of this communication of information contained herein is strictly prohibited. Brinton Vision reserves the right to charge a fee for records requested to be sent to the patient or other medical providers.