Southeast Connecticut Eye Care, LLC

Request for Medical Records

Patient requesting records:

First name:_____________ Last:_________________ Date of birth:___________


Facility to release records:

__________________________________________________________

Please send a copy of my medical records to:

_____ Myself. My mailing address is: _____________________________________________________

_____ Southeast Connecticut Eye Care, LLC (1041 Poquonnock Road, Groton, CT 06340, tel: 860-373-4148, fax: 860-661-0180)

Records requested:

_____ A reasonable period that adequately covers important issues in patient's care, as determined by a clinician in your practice

_____ From:_________________ To:_________________

_____ Complete medical record

_____ A summary of care letter dictated by a physician in the practice

Certification:

I hereby request a copy of my medical records as described above.

Patient:_____________________________________ Date:_____________

Guardian or Power of Attorney (if any):______________________________ Date:_____________