Documentation Request

Patient First Name

Patient Last Name

Date of Appointment

Date of birth

I hereby authorize Urgent Eyecare to disclose my protected health information (PHI) as described below. I understand that my PHI may include medical records, treatment details, billing information, and other relevant data.

I understand that by submitting this form, I am requesting the release of my personal health information (PHI) as specified. I acknowledge that I have read the Notice of Privacy Practices and consent to the release of this information under the guidelines of HIPAA. I confirm that the information provided is accurate and that I am the patient or legally authorized representative making this request.

Please let our office know exactly what documentation you need so we can ensure you receive the correct information.

Confirm with your initials

To request an itemized receipt, doctor’s note, or any other specific documentation from your visit, please fill out the form below. Our office will process your request and provide the requested items within 1-2 business days.

Thank you for choosing Urgent Eyecare!