Records Release

Complete this section if you want to send your full records to or from another facility.

By listing individuals below, you authorize Better Vision Family Eye Care to discuss your appointments, treatment, and financial information with them.

• Right to Revoke: I understand that I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.
• Re-disclosure: I understand that once the information is disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.
• Condition of Treatment: I understand that Better Vision Family Eye Care cannot condition my treatment or payment on whether I sign this authorization.
• Expiration: This authorization will expire one year from the date of signature unless a different date or event is specified here: