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PACIFIC EYE CARE CENTER 1270 Arroyo Way, Walnut Creek, CA 94596 RECORDS RELEASE AUTHORIZATION Phone:(925) 9458188 Fax:(925) 9450360 Website: www.pacificeyecarecenter.org Patient Name: Address: Date
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01
Access the pacificeyecarecenterorg website and locate the records releasepdf form.
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Read through the instructions provided on the form to familiarize yourself with the process.
03
Begin by filling out your personal information, including your full name, date of birth, and contact information.
04
Provide the details of the records you are requesting, such as the specific dates or time period, types of records (medical records, billing statements, etc.), and any additional relevant information.
05
If applicable, indicate the purpose for requesting the records and any specific individuals or organizations to whom you would like the records released.
06
Review the form for accuracy and completeness, making sure all required fields are filled in.
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Sign and date the form to certify that the information provided is true and accurate.
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Follow the submission instructions provided on the form, such as mailing or faxing the completed form to the designated address or contact information provided.
Who needs records releasepdf - pacificeyecarecenterorg:
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Individuals who have received medical or eye care services from Pacific Eye Care Center and need to obtain their medical records or related documents.
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Patients who are changing healthcare providers or seeking a second opinion and require their records to be sent to the new provider.
03
Legal representatives or insurance companies involved in a legal or insurance claim that require access to the patient's medical records from Pacific Eye Care Center.
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