Disclosure of Health Information Patient Name (First & Last)* Date of Birth* MM slash DD slash YYYY Email Address* Patient Address (Street, City, State, Zip)* Home Phone NumberCell Phone Preferred Contact* Home Phone Cell Phone Person Authorizing release of medical records* Patient Parent / Legal Guardian Other (Legal paperwork must accompany every release form if the requestor is not the patient or patient's guardian if the patient is under 18 years of age) Records requested FROMName of provider or organization* Address Phone #Fax #Web Address Records to be SENT TOName of provider* Address Phone #Fax #Web Address Please send: All records including lab work/biopsies Yes Please send: Records only (no lab work or biopsies) Yes Please send: Lab work/biopsies only Yes Other Reason for Disclosure of Use Personal Use Changing Provider Insurance 2nd Opinion Attorney Dissatisfied with Service Primary Care Review Reason for Disclose of User - Other* Additional Comments or InstructionsI do hereby consent and authorize you to release copies of my medical records, including current and previous medical records from other practices, practitioners, hospitals, and/or clinics that are a part of my medical records. PLEASE NOTE: This authorization includes consent for the release of alcohol, drug, psychiatric and psychological information; and any information related to pregnancy, sexually transmitted diseases, HIV testing, AIDS and any AIDS-related symptoms. It also includes any information concerning cancer, cancer testing and cancer results. I agree that a copy of this release shall be as valid as the original release. I understand the importance of following up with a dermatologies on a regular basis and I assume full responsibility for scheduling my own appointment with a dermatologies in the near future. I hereby state that i have read and fully understand the above statements as they apply to me. I hereby give consent to the user of disclosure of my medical records for the purpose stated above.Signature Type*PatientGuardianOtherSignature Type Description* Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Electronically signed by:* By completing this field, you understand that an electronic signature has the same legal effect and can be enforced as a written signature. You also agree that by signing this document you are in fact the individual identified as the person authorized to release records. In an effort to protect your health information, for any records release requests to be sent to an individual other than a medical office, our office will contact you directly by phone to confirm personal information prior to releasing this information.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
