www.currentderm.com - Medical Records Release

Medical Records Release

Authorization for Use or Disclosure of Protected Health Information
Patient Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
E-mail Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Release Information To:

I hereby authorize Current Dermatology and Cosmetic Center to release my protected health information to:
Name/Facility*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax*
Information to be Released (Select all that apply)
Progress NotesPathology and Lab ResultsOther
I understand that the information requested for release is specific to the above information only. I understand that my medical records may contain reports, results, and notes that only a physician can interpret. I understand and have been advised that I should contact my physician regarding entries made in my medical record to prevent my misunderstanding of the information covered in these entries. I will not hold any employee of Current Dermatology and Cosmetic Center liable for any misunderstanding of the information in my medical record as a result of not consulting with my physician for the correct interpretation. I further understand that I may revoke this consent (in writing) at any time to the extent that action has already been taken.
Signature*

Clear
Print Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Medical Records Release

Release Information To:

Information to be Released (Select all that apply)