Footwear Supply

Monroe Optical, INC





HIPAA Release Form for Prescription Eyewear
INSTRUCTIONS: This form allows your optometrist to release your eyewear prescription to us. It is REQUIRED if you do not know your prescription for your glasses. Please print, complete, sign, and fax this form to us at 1.800.888.4760

1751 N. MAIN ST. • FRANKLIN, IN 46131
PHONE: (317) 736-8958
TOLL FREE PHONE: 1-800-999-1522
FAX: 1-800-888-4760



* RELEASE OF PATIENT RECORDS*

PHYSICIANS NAME OR OFFICE: ___________________________PHONE:___________________FAX:_________________



PATIENT NAME: ________________________________________PHONE:________________________________________



DATE OF BIRTH: ______________________ADDRESS:________________________________________________________



* I DO HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS TO: MONROE OPTICAL, INC



PRINT NAME: ____________________________________________________DATE:_______________________________



PATIENT SIGNATURE: _________________________________________________________________________________



PRESCRIPTIONS ARE DATE-SENSITIVE. PLEASE CHECK WITH YOUR DOCTOR'S OFFICE TO ENSURE PRESCRIPTION IS CURRENT.