Download Eye Centers of Southeast Texas, L.L.P.

Eye Centers of Southeast
Texas, L.L.P.
Comprehensive Ophthalmology
Specializing in: Corneal Surgery,
External Disease, Glaucoma & Refractive Surgery
AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION
Name:
Date of Birth:
Tel. No.:
Street Address:
City:
State:
Zip Code:
The specific information that I wish to have released is:
All Clinical Medical Records
Other Records - Please list (e.g. billing, angiograms, photographs, etc.):
This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually
transmitted diseases, abortion, or mental health treatment. Separate 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.
Signature:
(Parent or Legal Guardian of Minor)
Date:
I understand that this authorization is valid for a ________ day period from the date that is signed.
I may revoke this consent at any time through written notice.
Release Records to:
Name:
Tel. No.:
Street Address:
City:
3345 Plaza 10 Drive
Beaumont, TX 77707
409-833-0444
______
State:
Zip Code:
Mailing Address:
PO Box 7160
Beaumont, TX 77726
www.eyecentersofsetexas.com
3129 College Street
Beaumont, TX 77701
409-838-3725