Authorization for Release of Medical Records - Dermatology Practice

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Release Information

I hereby authorize [Practice Name] to:

• Release my medical records TO
• Obtain my medical records FROM

Provider/Facility: _________________________________________ Address: ________________________________________________ Phone: ______________________ Fax: _______________________

Records to be Released

• Complete Medical Record
• Lab Results
• Pathology Reports
• Biopsy Results
• Clinical Photos
• Treatment Notes
• Specific Date Range: ____________ to ____________

Purpose of Release

• Continuing Care
• Insurance
• Legal
• Personal Use
• Other: ________________

Sensitive Information

I understand that my records may contain sensitive information. I specifically authorize the release of information relating to:

• HIV/AIDS testing and results
• Mental health treatment
• Substance abuse treatment

Understanding and Signature

• This authorization expires one year from the date signed unless otherwise specified
• I may revoke this authorization in writing at any time
• Treatment is not conditional upon signing this authorization
• Information used or disclosed may be subject to redisclosure

Signature: _________________________ Date: _______________

If signed by representative, state relationship: ________________

For Office Use Only

Request processed by: _________________ Date: ______________ ID verified: □ Yes □ No Method: ___________________________