RECORD RELEASE FORM

Please contact your previous place of service to get a copy of your records either sent to yourself or FAX / mailed to us prior to your first visit. Thank You.

Dr. Rob Gerowitz

Optometrist - Orthokeratologist

Mission: Myopia Control, P.C.

2723 Sheridan Rd, Suite C

c/o The Inn on Sheridan, Zion IL 60099

AUTHORIZATION FOR THE RELEASE OF HEALTH INFORMATION RECORDS

THIS AUTHORIZATION IS BEING COMPLETED BY: _____ PATIENT _____ LEGAL REPRESENTATIVE

On _____ / _____ / _____

Patient Name: ______________________________________

Date of Birth: ______ / ______ / ______

Patient Address: _______________________________________________________________________

Location of Records: Eyecare of Palatine, 4880 Euclid Ave #101, Palatine IL 60067 or

Other location: _________________________________________________________________________

As the patient or patient’s legal representative, I authorize the information requested to be released to:

Dr. Rob Gerowitz, Optometrist – Orthokeratologist, Mission: Myopia Control, P.C.

2723 Sheridan Rd, Suite C, c/o The Inn on Sheridan, Zion IL 60099

Phone 224-338-6692 / Fax 224-306-2848 / robgerowitz@gmail.com

This request is for ALL RECORDS ON FILE FOR THE PERIOD OF JANUARY 1, 2023 TO PRESENT and shall be delivered via:

_____ FAX to 224-306-2848

_____ Secure email

_____ USPS Mail delivery

_____ In-person pick up by either the patient or legal representative listed above

The records on file FOR THE PERIOD OF JANUARY 1, 2023 TO PRESENT requested above shall include the following for Continuation of Care:

__X__ ALL COMPREHENSIVE EXAM ENCOUNTERS

__X__ PROGRESS CHECK UPS; INCLUDING BUT NOT LIMITED TO ORTHOK /MYOPIA MANAGEMENT, STANDARD CONTACT LENSES, SPECIALTY CONTACT LENSES

__X__ BASELINE AND MOST RECENT CORNEAL TOPOGRAPHIES

__X__ MOST RECENT RETINAL IMAGES

__X__ BASELINE AND MOST RECENT OCT IMAGING

__X__ ALL MEDICAL ENCOUNTERS

On behalf of the patient or legal representative:

1. I understand I may revoke this authorization at any time by notifying the practice of request in writing and it will not affect any release of information prior to such request

2. The practice of request will not place conditions on treatment, payment, or eligibility for benefits on the basis of my signature below

3. I understand the information requested above is protected by HIPAA

4. I understand this authorization is valid for a period of one year from the above date of request

5. I understand I shall receive a copy of this signed form if requested

6. I understand this authorization relates to all records designated above. My signature gives my express consent to release this information.

Signature of Patient or Legal Representative ______________________________________________

Name of Patient or Legal Representative _________________________________________________

Relationship to Patient ______________________________ or Self _____