Authorization for Release of Medical Records

  • Release my records from:

  • Release to:

    Valley Eye Clinic & Optical
    223 E First Street Ste 101
    Jordan MN 55352

    Phone: 952-492-2350
    Fax: 952-492-6162
  • Please release a copy of all my medical records, including but not limited to: eye examinations, contact lens information, medical information, eye tests and screenings.

    By my signature, I authorize release of medical records.
  • Date Format: MM slash DD slash YYYY