Release of Medical Records

PATIENT'S NAME:

DATE OF BIRTH:

RELEASE OF PATIENT'S MEDICAL RECORDS TO:

I,

State Your Name

HEREBY AUTHORIZE THE RELEASE OF PATIENT's MEDICAL RECORDS TO:

DOCTOR/ CLINIC:

ADDRESS:

FAX NUMBER:

PHONE:

Please release the following:

I consent to the release of information related to HIV/AIDS or infection with any other communicable diseases and information related to behavioral or mental health services and treatment for alcohol and drug abuse, with the rest of the medical records

Yes, I consent to the release of this informationNo. do not consent to the release of this information

PURPOSE OF DISCLOSURE

I understand that I may revoke this authorization in writing at any time. Otherwise, this authorization shall remain valid until such time as it is revoked in writing.

Signed this day:

Date

Patient/ Parent / Guardian of Patient

1601 Whitehorse-Mercerville Road, Suite 2, Hamilton, NJ 08619 609-838-9040 pobletedermatology@gmail.com

www.pobletedermatology.com

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION