Use this form to digitally sign and electronically submit for release of medical information FROM Azar Eye Clinic TO Dr. Keating at Desai Eye Care. On submission this page will generate a signed PDF which will be sent to Azar Eye Clinic. Azar Eye Clinic will then release your medical recrods and send them to Dr. Keating at Desai Eye Care.

If you prefer to fill this form out on paper then scroll to the bottom of the page to view or download the PDF. You can emial the completed and signed form to [email protected] or fax to 337-234-8230 with “Attention Mrs. Jackie – Medical Information Release” on the cover page.

I authorize the release of the following protected health information (check all that apply):

The purpose for this request to release medical information is (check all that apply):

I further agree that this authorization shall be valid and effective unless it is revoked by me in writing and that a photocopy and/or digital image of this authorization may serve as an original.

If the patient is a minor or is unable to sign and you are a parent, legal guardian, or personal representative signing on behalf of this patient, please sign above and also complete the following: