Patient Forms
Medical Records Request
Our Medical Records Release Form is used for two purposes: authorizing Pacific Eye Associates to release your records to another party, or requesting that we obtain your records from another provider on your behalf.
Please complete all required fields, check the box(es) that apply to your situation, and sign and date the bottom of the form. If you are releasing records to another office, include the receiving office’s fax number or email address.
Record Release Fees
- Records sent directly to a patient: $15 for the first 20 pages, plus $0.25 per additional page
- Records sent office-to-office (physician-to-physician): No charge
Protected Health Information (PHI) Disclosure
If you would like our office to be authorized to discuss your care with someone other than yourself — a spouse, family member, or caregiver, for example — please complete the form below to provide written authorization.
Under HIPAA’s Privacy Rule, healthcare providers may not disclose a patient’s identifiable medical or billing information to any third party without the patient’s written authorization. This form serves as the mechanism by which you may grant such authorization.
Submitting Your Forms
Once completed, forms can be submitted using any of the following methods:
1. In Person
Bring the completed form(s) to your scheduled appointment, or drop them off at the front desk anytime.
2. Email
Send completed form(s) to eyeservices@pacificeye.com
3. Fax
Send completed form(s) to (415) 923-6586.
Please include your first and last name and date of birth on all forms to help us process and store your paperwork accurately.
