MEDICAL RECORDS REQUEST
Patient's Name
*
First Name
Middle Initial
Last Name
Home Address
*
City, State, Zip
*
Date of Birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Social Security # (Optional)
Phone Number
*
Format: (000) 000-0000.
I authorize Associates in Dermatology to:
*
Release Information To: CUTISCO DERMATOLOGY (INCLUDING DRUG AND/OR ALCOHOL RECORDS; HIV TESTING RESULTS.
CutisCo Provider (Optional)
Please Select
Dr. Allison Britt
Dr. Anh Pham
Kyle Manning, FNP
Reason for Request:
*
Transferring to a new physician
Records requested by specialist
Moving out of the area (new address)
Other
Information to be provided:
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Laboratory Report(s)
Pathology Report(s)
Office Visit Summaries
Other
I understand that I have a 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 ASSOCIATES IN DERMATOLOGY in writing. The revocation will only be effective from the date it is received by ASSOCIATES IN DERMATOLOGY and will not apply retroactively.
RELEASE EXPIRY DATE (Optional)
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Signature of patient or parent/guardian (if minor)
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Printed name patient or parent/guardian (if minor)
*
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