Name: Laser Eye Institute
Price range: $$$

Patient Name(Required)

First Last

Date of Birth(Required)

Patient Email(Required)

Enter Email Confirm Email

Contact Phone Number(Required)

Information Processing

Information To Be Released(Required)

All Clinical Medical Records

Other

Medical Release(Required)

This medical record may contain information about physical or sexual abuse, alcoholism, druge abuse, sexually transmitted diseases, abortion, or mental health treatment. Seperate consent must be given before this information can be released.

I consent to have the above information released

I DO NOT consent to have the above information released.

HIV Release(Required)

This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Seperate consent must be given before this information can be released.

I consent to have the above information released

I DO NOT consent to have the above information released.

Records Processing

Fees are assessed in accordance with the State of Michigan Medical Records Act. The records processing fee includes records of up to 20 pages in lengh and the administrative cost to prepare the records. If the records contain more than 20 pages the following fees will be assessed: Pages 21-50: $1.63/page Pages 51+: $1.25/page

Records Processing Type(Required)

Standard Processing (30 Days) - $45 USD

Rush Processing (2 Days) - $225 USD

Delivery Method(Required)

Secure Email

Mail

Fax

Delivery Mailing Address

Street Address Address Line 2 City State Zip Code

Delivery Fax Number

Delivery Email Address

Enter Email Confirm Email

Payment and Authorization

Total Amount Due

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Authorization(Required)

I agree and authorize Laser Eye Institute to release my medical records.

I understand that this authorization is valid for a 15-day period from the date that is signed. I may revoke this consent at any time through written notice. Fees are assessed in accordance with State of Michigan Medical Record Access Act. I understand that Laser Eye Institute has the right to refuse to copy medical records until fees are paid.

Patient Signature(Required)

Medical Records Request

Information Processing

Records Processing

Payment and Authorization