Release Form from Nashoba Vision

Records of Release

Patient Name:

Home Address:

Phone:

Date of Birth:

I hereby authorize my protected health information to be disclosed to the office of:

Address:

Phone:

Fax:

From the office of:

Nashoba Vision
140 Main Street
Groton, MA 01450
Phone: (978) 448-5172
Fax: (978) 448-6353

I have read and understand the terms of this authorization and have had the opportunity to ask questions about the disclosure of my health information. By my signature below, I hereby knowingly and voluntarily authorize Nashoba Vision to request and/or disclose my health information in the manner described above.

Signature of Patient:

Date:

If the patient is a minor or is otherwise incapacitated (mentally or physically), obtain the following signatures:

Signature of personal representative:

Description of authority:

Date: