Medical Records Release

Date

Patient Name*

First NameLast Name

Patient Date of Birth*

Date

I hereby authorize VITAL DERMATOLOGY to disclose my protected health information by the method selected below. I understand that this authorization is voluntary. If the organization authorized to receive the information is not a health plan/health care provider, the released information may no longer be protected by federal privacy regulations. A photocopy/scanned copy of this form is valid as the original.

I request for Vital Dermatology to request my records from:*

Henghold Dermatology, fax 850-484-8223Medical Center Clinic, Derm, fax 850-474-8022Taylor Dermatology, fax 850-202-7015Tarantola Dermatology, fax 850-696-2613Summit Dermatology, fax (850) 518-3886Michael Caluda M.D., fax 850-434-3387Ascension Oncology, fax (850) 416-6934Other

Information to be sent (note: if not specified, the FULL RECORD will be requested):*

Full Medical RecordLast Office Visit NoteResultsOther

Additional Note

Information requested is Unlimited, unless otherwise specified. Please select if you do NOT want to disclose records related to:

Alcohol/Drug AbuseHIV resultsGenetic TestingMental Health/Disabilities

Expiration: Valid for 3 years, unless otherwise specified .

Patient/Representative Signature*

Signed by:*

PatientParent of Minor/ Legal GuardianPower of Attorney

Authorization of Disclosure of Health Information