Release Form

Authorization of Release Information

Patient Name:

Date of Birth:


I authorize Vision Park Family Eye Care


Release to

Obtain from

Verbally exchange with





Specific description of information (including date(s) of service):

The disclosure is for the following purpose(s):

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.

Signature of patients or patient's legal representative


Printed name of patient's legal representative:

Relationship to the patient:

Roya1234 none optometrist # # # 2699 86th St Urbandale, IA 50322 5152702490 5152702494 # 8:00 AM - 5:00 PM 9:30 AM - 6:00 PM 8:00 AM - 5:00 PM 9:00 AM - 6:00 PM 8:30 AM - 5:00 PM Closed Closed 640 South 50th St, Ste 2180 West Des Moines, IA 50265 5152258667 5152258784 # 9:00 AM - 6:00 PM 9:45 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 5:30 PM Closed Closed