Skip to main content
2 Convenient Locations
Home ยป Guardian-Parent Release Form

Guardian-Parent Release Form

  • MM slash DD slash YYYY
  • I authorize Vision Park Family Eye Care to release my medical information to:
  • MM slash DD slash YYYY
    or one year from the date signed.
  • I understand that I may refuse to sign this authorization or revoke this authorization at any time. I understand that my revocation or refusal to sign this authorization will not affect my ability to obtain health care services unless the services are at the request of the party to whom the protected health information will be disclosed. I also understand that if I revoke, the information described above may be re-disclosed and will no longer be protected by the regulations.

  • MM slash DD slash YYYY