Authorization for Release of Medical Records from Valley Eye Associates

Patient Name

Last Name

Mailing Address

Email

Date of Birth

Release Records From:

Records Release From Valley Eye Associates Location

21 Park Place
Appleton, WI 54914

2100 S Kensington Dr
Appleton, WI 54915

2500 E Capitol Dr, Suite 3500
Appleton, WI 54911

1301 E Northland Ave
Appleton, WI 54911

1543 Park Place, Suite 400
Green Bay, WI 54304

719 Doctors Court
Oshkosh, WI 54901

358 S Koeller St
Oshkosh, WI 54901

Release Records To:

Records Release To (doctor or clinic name)

Address

Fax Number

Type of Information to Be Released

Purpose or Need for Release

This authorization will be effective for medical records generated to the date of signature. I understand I may revoke this authorization at any time I may revoke this authorization at any time by providing my request in writing.

Clear

If patient is 18 or over, this MUST be signed by the patient. If signed by a person other than patient, please indicate why:

Patient is a minor

Patient is incompetent

Patient is deceased

What is your relationship to the patient?

Parent / legal guardian

Personal representative

Next of kin of deceased

Attach Copy of P.O.A.

Maximum file size: 20MB

Authorization for Release of Medical Records from Valley Eye Associates

Release Records From:

Release Records To:

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