Records Transfer

For healthcare providers only
This form is for healthcare providers requesting the transfer of a patient’s medical records. If you are a patient requesting a copy of your own records, please use the Patient Medical Records Request form.

Medical Records Transfer

Complete this form to authorize Laser Eye Institute to exchange your medical records with another healthcare provider.

Patient Name(Required)

First Last

Date of Birth(Required)

Patient Email

Enter Email Confirm Email

Contact Phone Number

Information Processing

Information To Be Transfered(Required)

Most Recent Exam

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.

Additional Details

Include any additional information for this request.

Records Processing

Healthcare Provider or Facility Name(Required)

Provide the name of the healthcare provider or facility name to coordinate records with.

Healthcare Provider Fax Number(Required)

Records delivered via fax. Provide providers fax number.

Patient Signature(Required)