Name: TotalVision Eyecare of Glastonbury
Address: 63 Hebron Ave, Glastonbury, CT, 06033, US
Telephone: (860) 659-5900
Price range: $000 - $300

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)
Hidden
Date
MM slash DD slash YYYY

Records to be sent to other doctors

Monday: 8:30 AM - 5:00 PM
Tuesday: 8:30 AM - 5:00 PM
Wednesday: Closed
Thursday: 9:00 AM - 7:00 PM
Friday: 8:30 AM - 5:00 PM
Saturday: 8:30 AM - 1:30 PM
Sunday: Closed

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TotalVision Eyecare of Glastonbury