MED RELEASE - ENGLISH

Release of Medical Records
1. I hereby authorize Oasis Dermatology Group, PLLC to release to Name of Recipient* the following information from medical records, including AIDS/HIV test results, diagnosis, treatment, and related information (if any), on:
Patient Name*
Date of Birth*

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Identification Card/Driver's License (Please upload a picture of the FRONT of card)*

Cancelof
FaxEmailMail
Recipient Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Recipient Email

Confirmation Emailexample@example.com
Entire Medical Record and BillingLab Results/ReportsOperative ReportsPathology ReportsAll Medical History/FormsImmunization RecordXray Results/ReportsConsultation ReportsProgress NotesOther
3. The above information is released for the following purpose only:

Patient Personal Record. Any other uses are forbidden.
4. If my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Patient Records, 43 CFR Part 2, I hereby agree to that those records be disclosed with this written consent.*

Clear
5. With respect to any mental health information which may be contained in the medical records, I hereby waive my right to the privileges of confidentiality and also agree to have these records disclosed with this request.

6. Patient Right to Revoke In Writing:

I also understand that I may revoke this authorization at any time in writing, except to the extent that action has been taken in reliance on it. This authorization expires automatically ninety (90) days from the date signed.

7. Prohibition of Re-Disclosure:

Federal rules, such as but not limited to HIPAA Requirements as written by HSS (U.S. Department of Health and Human Services), prohibit any further disclosure of this information unless disclosure is expressly permitted by HHS written consent of the person to whom it pertains. However, once released information leaves this facility, the information provided may be subject to re-disclosure by the recipient.

8. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing not obtaining this authorization, except if the authorization is for; (1) conducting research to related treatment; (2) obtaining information in connection with the eligibility for enrollment in a health plan, (3) determining an entity's obligation to pay a claim, or (4) creating health information to provide to a third party.
Adult Patient/Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Release of Medical Records