Records to be sent to other doctors Patient Name* First Last Date of Birth MM slash DD slash YYYY I authorize the use and/or disclosure of my protected health information as described below.I am authorizing TotalVision Eyecare of Glastonbury to release the following records on my behalf* Most recent eye exam Most recent eye test Office notes pertaining to Entire Medical Record Other Office notes pertaining to Entire Medical Record describe The reason for this release is because I am changing physicians For coordination of care with my other doctor I am moving and not sure of a new physician I would just like a copy for my records Give the requested information to:(Check one) Me Individual Named Below Office Name: Office Phone:Doctor Name: Office Fax:Address Street Address Address Line 2 City Method of disclosure:(Check one) I will pick up Mail Fax This authorization will expire 180 days from the date signed. I can revoke this authorization anytime in writing, however if the requested information has been already disclosed I realize it cannot be taken back. I have reviewed and I understand this authorization. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected under federal law. I also understand there may be fees of $0.65 per page per copy and for postage.Signature of Patient or Guardian*Relationship (if signed by Guardian) HiddenDate MM slash DD slash YYYY