Records Release from Nittany Eye Associates This authorizes: Nittany Eye AssociatesTo release records and/or information described below concerning:Patient's Full Name(Required) First Middle Last Date of Birth(Required) Month Day Year Address Street Address City State Zip If Nittany Eye Associates is releasing records to another provider please include contact information below:Name of PracticeAddress Street Address City State Zip Phone/FaxSpecific Records or Information to be Released:(Required)This consent will expire one year from date of authorization unless expressly revoked in writing by the patient or his/her agent.Date(Required) Month Day Year Patient's Signature or Authorized Party(Required) Δ
