Guardian-Parent Release Form

Please Select Location*
- Urbandale Office
- West Des Moines Office
Patient Name
First Middle Last
Date of Birth
I authorize Vision Park Family Eye Care to release my medical information to:
Name
First Middle Last
Relationship
Phone
Fax
The Disclosure is for the following purpose(s):
- Medical Records
- Prescription
- Billing and Insurance
Other
The release expires on

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 Representative
Date
Printed name of patient's Legal Representative
Relationship to the patient