DermaBlue - Authorization Form

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Patient's Name
Date of Birth

MonthDayYear
Date
Which DermaBlue office location do you receive care at?

DermaBlue AshevilleDermaBlue Hendersonville
I hereby authorize DermaBlue and its employees to release or obtain (check the appropriate box below) I hereby authorize DermaBlue and its employees to information pertaining to my medical care and treatment, including, but not limited to, mental health records, drug and alcohol abuse records and diagnosis and/or treatment of HIV (Aids Virus).
Authorization*

ReleaseObtain
Release To:
Obtain From:
Release To:
Obtain From:
Release To:
Obtain From:
I understand that I may revoke this consent at any time, and that upon fulfillment of the above-stated purpose or lapse of 12 months from the date of signature, whichever comes first, this consent will automatically expire without my express revocation, but that revocation may not be applied retroactively once the information has been released in good faith. | understand DermaBlue and its staff cannot be responsible for confidentiality of information disclosed after said information has been released pursuant to this authorization, and I hereby release them from any liability arising from such disclosure and from all legal responsibility or liability that may arise from this authorization.
Signed*

Clear
Date

MonthDayYear
Date
Witness
Date

MonthDayYear
Date
If not signed by the patient, please indicate relationship

Parent or Guardian of minor patientGuardian or conservator of an incompetent patientBeneficiary or personal representative of deceased patient
DermaBlue

New PatientEstablished Patient
1998 Hendersonville Rd, Unit 53 | Asheville, NC 28803 | 828-585-5489
120 South Grove Street | Hendersonville, NC 28792 | 828-685-2917
Should be Empty:

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION