"*" indicates required fields PERMISSION TO RELEASE PATIENT RECORDSPatient name* First Last DOB:* MM slash DD slash YYYY To:Fax #:I hereby grant permission to this office to release my patient records to Richard H. Miyasaka, O.D., LLC (dba Miyasaka Eye Care). The medical findings and treatment records should cover all examinations, spectacles and/or contact lens prescription information. In granting this request, I hereby release my practitioner from any laws governing the disclosure of confidential or privileged information.Signature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
