R. Raj Gupta, M.D.

Ophthalmic Plastic, Reconstructive, and Orbital Surgery

Cosmetic Eyelid Surgery

5575 Warren Parkway Suite 210 Frisco, TX 75034 Office: 214-618-3937

10210 North Central Expressway Suite 125 Dallas, TX 75231 Office: 214-369-5343

Medical Records Release Form

This authorizes Vista Ophthalmology Associates, P.A. to provide a copy, summary, or narrative of my medical records as indicated by the checkmark(s) below or otherwise release confidential information.

o  Complete Records

o  Records of care from the following dates: ______to ______.

o  Records concerning the following conditions: ______.

o  Other, please specify: ______.

o  Confer with person(s) listed below orally about my medical information:

Patient Name: ______

Patient Date of Birth: ______

Release to the following person(s) or provider(s):

Name: ______

Address: ______

City: ______State: ______Zip Code: ______

Telephone: ______

Fax: ______

The reason or purpose for this release of information is as follows:

______

______

Patient or Legal Guardian Signature Date

Please Note: According to Texas Administrative Codes 165.2(e) and 165.3, Vista Ophthalmology Associates, P.A. may charge the following fees for copying, mailing, and/or faxing medical records. The requested information may be retained until payment is received.

  1. First 20-pages $25.00
  2. Each page thereafter $0.50 (per page)
  3. Diagnostic Images $8.00 (per image)
  4. Mailing/Shipping Actual Cost