Medical Records Request Forms

If you are a new patient or have not visited us within a year, we ask that you print and complete these patient forms prior to your visit.

If you have any questions about the information required on the forms, please call (954) 741-5555 and a member of our staff will be happy to assist you.

Or you can download individual forms separately:

Request to receive

English

• Authorization for Fort Lauderdale Eye Institute to receive medical records from your provider

Español

• Autorización Para Proporcionar Información

Request to release

English

• Authorization for Fort Lauderdale Eye Institute to release your medical records to another party

Español

• Autorización Para La Liberaciòn De Registros Mèdicos A Enviar Desde

*Florida statute 395.3025 allows a fee of up to $1 per page for medical records. 

Per our policy we charge $1 per page for the first 25 pages and then .25 cents for each additional page

EXCLUDING COLORED PHOTOS WHICH MAY INCUR AN ADDITIONAL CHARGE (payment must be received prior to releasing records)

Delivery methods include: In-person pickup, USPS, or via fax