Medical Records Release Form

Use this form to ask another eye doctor, hospital, or clinic to send your records to North Indiana Retina. It takes about two minutes. Once you sign, we fax the request for you.

1Your information

First name *

Last name *

Date of birth *

Phone *

Sex *

As listed with your other doctor, so they can find your chart.

Optional

Street address *

City *

State *

ZIP *

2Who has your records?

Doctor, clinic, or hospital *

Start typing. If we already have their fax number it will fill in automatically.

Their fax number *

Found on their website or by calling their office.

Their phone

Optional

Their address

Optional

Records will be sent to North Indiana Retina, 303 S Main St, Suite 215, Mishawaka, IN 46544. Fax 260-279-3211, phone 574-291-4000.

3What should they send?

Records to release *

Dates of service

All dates Specific dates

Purpose of release

4Authorization

I authorize the provider or facility named above to release the records I selected to North Indiana Retina.

I understand that:

Signing this form is voluntary. My treatment, payment, enrollment, or eligibility for benefits does not depend on it.
I may cancel this authorization at any time by writing to the provider named above, except where they have already acted on it.
Once released, the information may be re-disclosed by the recipient and may no longer be protected by federal privacy rules (HIPAA).
Unless I limited it above, the records may include information about mental health, substance use, HIV/AIDS, or genetic testing.
This authorization expires one year from the date I sign it unless I cancel it sooner.
I may have a copy of this form. A fax or electronic copy is as valid as the original.
My electronic signature below is the legal equivalent of my handwritten signature.

I have read and agree to this authorization, and I confirm that the information I entered is accurate. *

5Sign

I am signing for the patient as their parent, guardian, or legal representative

Sign here

Use your finger, stylus, or mouse.

Your information is sent securely and faxed directly to the office you named. Need help? Call 574-291-4000.