Opt-In and Release of Information Form

  • By signing this form, you attest to opting in to sharing of your medical, financial and health insurance information with Midwestern University's Eye Institute for the purposes of vision screenings and services. This form also allows NATIVE HEALTH to receive results related to your vision appointment. Please be aware that if you do not opt into this information sharing, you will not be able to participate the Midwestern University's Eye Institute Eye Exams and Eyeglass program.

  • MM slash DD slash YYYY
  • Please Initial:


  • MM slash DD slash YYYY