Records Request

Patient Name

DOB

Address

Street Address City State ZIP Code

Requesting Records From:

Physician Name

Office Name

Address

Street Address City State ZIP Code

Phone

Fax

**Please Include Records for the patient’s last TWO exams and glasses/contact lens orders from applicable exam dates**

Releasing Records to:

Dr. Cary Barnett, O.D. and Dr. Holly Richards, O.D.
Steiner Eye Care
6111 Ranch Road 620 N Building A Suite 100
Austin, Texas 78732

Phone: (512) 439-2020 Fax: (512) 772-2980

I understand that this authorization will be valid for one (1) year unless otherwise stated or revoked written notice is given.

By signing this form, I authorize these providers to release or receive confidential health information about me, by releasing either a full copy or a summary of my medical records/protected health information. I understand that this information will be provided within 15 days from receipt of request and that a fee for preparing and furnishing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners.

Signature of Patient/Guardian

Date