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Medical Records Request

Home Medical Records Request

J. Britt Wright,OD
4185 Technology Forest Blvd. Ste 225
The Woodlands ,TX 77381

    MEDICAL RECORDS REQUEST (* required)

    INFORMATION REQUESTED:

    I authorize the above named provider/entity to release the following designated medical information

    Copy of complete medical records including results of diagnostic testingCopy of contact lens prescriptionCopy of spectacle lens prescriptionComplete Billing Transaction History

    Release Authorized to:

    J. Britt Wright OD
    4185 Technology Forest Blvd Ste 225
    The Woodlands TX 77381
    Fax: 281-362-5764

    I HAVE READ AND UNDERSTAND THIS FORM. I VOLUNTARILY AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM. IF I AM SIGNING FOR A MINOR, MY SIGNATURE ATTESTS THAT I HAVE LEGAL AUTHORITY OVER MEDICAL DECISIONS FOR THE DESIGNATED MINOR.