theskincenter.com - Records Request Form

Records Request Form

Please fill out this request as completely and clearly as possible. We are unable to release your information unless it is specifically defined in this authorization.
PATIENT INFORMATION
Name:*

First NameLast Name
Date Of Birth: *

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
WHO MAY RECEIVE YOUR MEDICAL RECORDS?*

A Medical PracticeAn Individual or Individuals
Name of Practice or Provider:*
Phone Number and/or Address:*
Name(s):*
Relationship:*
Phone Number and/or Address: *
WHAT INFORMATION IS BEING REQUESTED?*

Visit NotesPathology ResultsOther (please specify):
DATES OF SERVICE REQUESTED:*
You MUST specify dates of service or a specific time frame (example: “1/29/25, 2/27/25, 3/11/25”, or “January 2025 through March 2025”.) We will not release records without this information.
PURPOSE OF REQUEST?*

Continuation of Medical CareInsurance or Financial PurposesPersonal RecordsOther

EXPIRATION DATE and RIGHT TO TERMINATE OR REVOKE AUTHORIZATION
This authorization will be considered valid for 30 days from the date of request and will not be honored without a dated signature. You may extend or revoke this authorization at any time by sending written notice to:

JAY S. HERBST, M.D. – Privacy Officer
SOUTH FLORIDA SKIN CENTER
TAMIAMI TRL, STE A
PORT CHARLOTTE, FL 33952

Any extension or revocation of this authorization requires written notice and “open-ended” or non-specific authorizations will not be considered valid for release of records.

PATIENT RIGHTS, DISCLAIMERS, and FEES

This authorization is compliant with all rights as set forth in this facility’s privacy notice. Information authorized for disclosure may be disclosed again by the individual or organization authorized to receive the protected health information requested for release. You may inspect or copy the information specified in this authorization. You may refuse to sign this authorization. Refusal to sign this authorization will not result in denial of care or treatment by the South Florida Skin Center. Any fees associated with the release and handling of information included in this authorization will not exceed allowed amounts as specified by state and federal laws.

The use of this authorization form is intended only for the patient or patient representative as specified by the patient. Any patient representative must be listed as an authorized individual in the patient’s healthcare record. Any guardian or Power of Attorney must provide documentation of appointment prior to the release of any protected health information.
I Name* , have read and understand the terms of this agreement. I understand that I may ask questions regarding this agreement and that by signing this authorization I confirm that I have the mental capacity to understand the terms of this agreement.
Signature of Patient or Patient Representative*

Clear
Relationship to Patient*
Date*

MonthDayYear
Date
Should be Empty:

Records Request Form

PATIENT INFORMATION

EXPIRATION DATE and RIGHT TO TERMINATE OR REVOKE AUTHORIZATION