Records Release Request

My records are being requested:*

FROM Clarity Eye Care TO another person or office

FROM another person or office TO Clarity Eye Care

Which information from your records would you like released?*

Last examination record including most recent testing

Records from a specific range of time

Complete medical history

What is the reason you are requesting this records transfer?*

Changing providers

Patient's own personal use

Other (please note below)

I have read the above and authorize the disclosure of such health information as described. I understand that treatment is not conditioned upon the execution of this authorization.

I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations.

I understand that Clarity Eye Care may charge a fee for the costs of copying, mailing, or other supplies or services associated with this request.

I understand that I may revoke this authorization at any time by providing a written notice to the person identified below except to the extent that action has been taken in reliance upon it or except as otherwise stated in Clarity Eye Care's Notice of Privacy Practices by mailing or hand-delivering written notification to the following person: Attn Privacy Officer, 11811 Fort St. Ste 105, Omaha, NE 68164.

Clarity Eye Care is not responsible for completeness, legibility, or omittance caused by the copying of any medical records from another institution.

Are you (the person completing this form) the patient, or a representative or guardian?*

I am the patient

I am a representative or guardian

Signature of Patient or Authorized Patient Representative:*

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Clarity Eye Care Records Release Authorization