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THE WILMER EYE INSTITUTE AT JOHNS HOPKINS: REQUEST FOR RELEASE OF HEALTH INFORMATION INSTRUCTIONS: Please complete this page and the Authorization for Release of Health Information [click for the link]. Requests that are incomplete will not be honored, and may be returned. Write “N/A” if sections are not applicable. If in agreement with the terms on those forms, fill in the name of the patient’s provider, or the Wilmer division in which he/she was seen, in order to authorize the release of records. For a listing of all Wilmer providers, click on the “Providers by Specialty and Location” link on the home page, www.hopkinsmedicine.org/wilmer. After completing all forms, please fax them to the applicable Wilmer office [information below], using this page as a cover sheet. You may also submit them in-person, or mail them to: Wilmer Eye Institute 600 North W olfe Street Baltimore, MD 21287 If you need assistance, please call: 410-955-5080 The current rate for copying medical records is $0.73 per page. There is also a $22.09 preparation fee, though patients are not responsible for this cost. All rates and policies are in compliance with Maryland State guidelines. FAX NUMBERS BY LOCATION AND DIVISION: The Wilmer Eye Institute at the Johns Hopkins Hospital Comprehensive Eye Service Cornea Echography General Eye Service Glaucoma Low Vision Neuro-Ophthalmology Oculoplastics Photography Retina Pediatric Ophthalmology & Adult Strabismus Uveitis & Ocular Immunology Visual Function 410-614-1670 410-955-0867 443-287-5182 410-614-8496 410-955-1985 410-502-6707 410-614-9240 410-614-9987 410-955-3838 410-955-0869 410-955-0809 410-955-2924 410-614-7965 Wilmer at Bayview Medical Center Bayview Optometry 410-550-2231 410-550-8098 Wilmer at Columbia 410-910-2393 Wilmer at Frederick 301-620-9228 Wilmer at Green Spring Station Surgery Center at GSS 410-583-2842 410-583-2814 Wilmer at Odenton 410-874-1429 Wilmer at Bel Air 410-893-9796 Wilmer at White Marsh 443-442-2021 Wilmer at Wyman Park 410-338-3555 RECORDS REQUEST Patient’s Physician at Wilmer Wilmer Division Where Seen Patient Last Name, First Name Best Contact Phone Number *If you plan to submit these forms via fax, find the applicable Wilmer location or division on the left, and send them to the associated number. Wilmer Staff: contact patients or patient representatives at the above number if additional information or verification is needed.
