Authorization for Release of Medical Information

Authorization for Release of Medical Information
Patient*
Date*

MonthDayYear
Date
Address*
DOB*
CityStateZip*
I authorize Alaska Family Dermatology, LLC to (Choose only one)*

Send copies of my record to (and discuss information with) the provider/person/facility belowReceive copies of my record from (and discuss information with) the provider/person/facility below
Name of Provider/Person/Facility*
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Phone Number
Fax
Please enter a valid phone number.
Information to be disclosed*

Most Recent Visit NotePathology ReportsLab Reports (last 12 months)Operative NotesFull Medical RecordOther
Restrictions: Only medical records originated through this healthcare facility will be copied unless otherwise requested. This authorization is valid only for a one-time release of medical information dated prior to and including the date on this authorization unless other dates are specified. There may be a charge for the requested records. The records above may be faxed in the case of medical necessity. This authorization may be canceled at any time by submitting a written request to Alaska Family Dermatology, LLC.

I have read the above Authorization for Release of Medical Information and acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

Parent/Legal Guardian/Power of Attorney signature required for minor (less than 18 years of age) or for a patient who has been deemed unable to do so.
Patient/Representative Signature*

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Date*

MonthDayYear
Date
Relationship to patient (if other than self): Printed name of Authorized Representative:
Relationship to patient if other than self
Printed name of Authorized Representative
3340 Providence Drive, Ste 358 I Anchorage, AK 99508 I 907-268-2067 Fax: 855-395-0858
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