Records Request form

Clarity Eye Center, 4337 Teravista Club Dr, Round Rock, TX 78665, Ph: 512-244-7200, Fx: 512-868-3907

I understand that if I request records mailed to myself, there will be a fee assessed.
Note: This authorization is good for the initial record disclosure and for any subsequent disclosure to the same party for a period not to exceed 30 months unless otherwise specified by me. I understand that I may refuse authorization to disclose all or some of my health care information, but that a refusal may result in improper diagnosis, denial of coverage or a claim for health benefits and other insurance, or other adverse consequences.
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