Free Medical Release Form 10
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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:
Na