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  • Authorization for Disclosure of Health Information

  • I hereby authorize the use of disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider; the released information may no longer be protected by federal privacy regulations.

  • Patient Information:

  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • To Disclose To CutisCo Dermatology:

  • Disclosure method:*
  • Information to be released:*

  • Release records from the time period of to . If left blank, only the past two (2) years will be disclosed.

  • Unless checked or listed below, I understand that the following information may be released (as defined by applicable state and federal laws). Check and/or list if you do not want to disclose:
  • Purpose(s) of the disclosure: (check all that apply)*
  • Your Rights with Respect to this Authorization: I understand that I have a right to inspect and receive a copy of the material to be disclosed. I understand that written notification is necessary to revoke this authorization, except to the extent that information may have been released before receipt of this notice. My decision to sign this authorization will not affect my treatment. If this information is being disclosed to an individual or entity that is not a health care provider or health plan, it may be subject to re-disclosure and no longer protected. A photocopy/facsimile or scanned copy of this form is valid as the original.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • If signed by a person other than the patient, complete the following:
  • *By signing above, I hereby declare that I have not been denied physical placement of this child.
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  • Should be Empty: