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.