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Dr. Linda Dejmek O. D. FCOVD Neuro-Developmental Optometrist Vision Therapy Centers SC 1466 Kenwood Dr. POA for Healthcare Disabled DATE Spouse/Adult Family Member of Deceased Patient Deceased Updated 5/24/12. Menasha WI 54952 Office 920-722-2020 Toll Free 888-613-2020 Fax AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION email info abseevision.com PATIENT Name of Patient/Previous Names Birth Date/Medical Record Number Street Address City State Zip Code AUTHORIZES RELEASE OF PROTECTED HEALTH...
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