Guardian-Parent Release Form Please Select Location* Urbandale Office West Des Moines Office Patient Name First Middle Last Date of Birth MM slash DD slash YYYY I authorize Vision Park Family Eye Care to release my medical information to:Name First Middle Last Relationship PhoneFaxThe Disclosure is for the following purpose(s): Medical Records Prescription Billing and Insurance Other The release expires on 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.Patient Signature or Patient's Legal RepresentativeDate MM slash DD slash YYYY Printed name of patient's Legal Representative Relationship to the patient
