Transfer Records

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Request for Medical Records

Artisan Pediatric Eyecare provides one single copy, upon request, of you or your child’s medical record at no charge. You may either request that this copy of your records be sent to you, or be forwarded to another provider’s office. 

Transfer Records

*Date
*Patient's Full Name
*Patient Date of Birth
*Street Address*City*State*Zip Code
 
I hereby authorize the release of my medical and/or optical records and request that they be transferred from:
 
*Doctor*Address*PhoneFax
 

 

My personal health information, and complete medical records may be released to the Doctors affiliated with:

Artisan Pediatric Eye Care (please fax the requested information as noted below)

Artisan Pediatric Eye Care
7960 W. RIFLEMAN STREET, #110
BOISE, IDAHO 83704, USA
PHONE: 208.900.3336
FAX: 208.639.0329

This records release is valid for 1 (one) year from the date of signing. This records request is for the purpose of continuation of care. Artisan Pediatric Eye Care is not liable for any fees associated with the release of the requested information. The patient bears that liability, and requests to be notified in advance of any charges for the release of PHI and/or medical records.

 
The purpose of this release is to obtain:


If you selected other, please explain:Patient SignatureGuardian Signature (If patient is a minor) 

REQUEST MORE INFO

*NameEmail*Phone*Interested InMessage