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I hereby authorize the release of my medical and/or optical records and request that they be transferred from:
My personal health information, and complete medical records may be released to the Doctors affiliated with:
Artisan Pediatric Eye Care (please fax the requested information as noted below)
Artisan Pediatric Eye Care
7960 W. RIFLEMAN STREET, #110
BOISE, IDAHO 83704, USA
PHONE: 208.900.3336
FAX: 208.639.0329
This records release is valid for 1 (one) year from the date of signing. This records request is for the purpose of continuation of care. Artisan Pediatric Eye Care is not liable for any fees associated with the release of the requested information. The patient bears that liability, and requests to be notified in advance of any charges for the release of PHI and/or medical records.
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