Release of Records FROM Family Vision Solutions Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY TO: FAMILY VISION SOLUTIONS 2827 Waterbend Cove, Suite 100 Spring, TX 77386PLEASE RELEASE COPIES OF THE FOLLOWING RECORDS PER MY REQUEST:(Required) Complete eye care records Current exam and prescription(s) Current prescription(s) only Please forward my records to: (mailing fee $25.00)Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code FAX:(Required)I hereby request the release of records to the person listed below:Date(Required)SignatureSigned By Patient/self Guardian Please send the above information at your earliest convenience. Δ
