Pariser Dermatology Medical Release Form

PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
First and Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Description of the information to be used or disclosed:
Description of the information to be used or disclosed:

Other
Pariser Dermatology Specialists, Ltd., may disclose/discuss my protected health information to/with CutisCo Dermatology.
CutisCo Provider (Optional)
I understand Pariser Dermatology Specialists, Ltd. is authorized by me to use or disclose my protected health information for a purpose other than treatment, payment, or health care operations. I have read this authorization and understand what information will be used or disclosed, who may use and disclose the information, and the recipient(s) of that information. I specifically authorize Pariser Dermatology Specialists, Ltd., to disclose my protected health information as described on this form to the recipients listed below. I understand that when the information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected health information. I understand I retain the right to revoke this authorization and the right to inspect or copy the information to be disclosed. I may refuse to sign the authorization.
This authorization will expire ONE YEAR from the date on this authorization. After this date, PARISER DERMATOLOGY SPECIALISTS, LTD. can no longer disclose my protected health information without first obtaining a new authorization form.
I fully understand and accept the terms of the Patient Authorization for Release of Medical Records.
Patient's/Patient's Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Description of the information to be used or disclosed: