Peninsula Dermatology Medical Release Form

MEDICAL RECORD RELEASE
Patient Information

First NameMiddle InitialLast Name
Social Security #
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Home Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City, State, Zip
I AUTHORIZE PENINSULA DERMATOLOGY SPECIALISTS TO:
Select Provider (Optional)
PURPOSE OF THE USE OR DISCLOSURE:
PURPOSE OF THE USE OR DISCLOSURE:

Other
REASON FOR REQUEST:
REASON FOR REQUEST:

Other
INFORMATION TO BE PROVIDED:
INFORMATION TO BE PROVIDED:

Other
I understand that I have the right to refuse to sign this RELEASE. I understand that this RELEASE is valid for 12 months from the date of signature below, unless otherwise noted.

I understand that there will be a fee for copying medical records. I understand that I may revoke this RELEASE at any time by notifying DERMATOLOCY SPECIALISIS in writing. The revocation will only be effective from the date it is received by DERMATOLOCY SPECIALISIS and will not apply retroactively.
RELEASE EXPIRY DATE (OPTIONAL)

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Signature of patient or parent/guardian if minor
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Printed name of patient or parent/guardian if minor
Relationship to Patient
Should be Empty:

MEDICAL RECORD RELEASE