HIPAA - Auth to RELEASE Records

Authorization for McLean & Potomac Dermatology and Skincare Center to RELEASE Medical Information
Patient Full Name (if name has changed, please specify*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Patient Cell Phone Number*

Area CodePhone Number
Patient Home Phone Number

Area CodePhone Number
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The above patient or their parent/legal guardian authorizes McLean Dermatology and Skincare Center, located at 6849 Old Dominion Drive, Suite 450, McLean, VA 22101; OR Potomac Dermatology and Skincare Center, located at 9812 Falls Road, Suite 124, Potomac, MD 20854, to make a disclosure of medical record information to the following individual or facility:
Name of Individual or Organization from which McLean & Potomac Dermatology and Skincare Center will release medical record information:*
If you are listing a medical practice, be sure to list your medical provider as well - in the box above.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax Number*

Area CodePhone Number
Type of Information to Disclose: (Check all that apply)*

Entire RecordPathology Results OnlyBlood or Culture Test Results OnlyReceipts and Billing Information OnlySpecific Visit notes and/or Test Tesults
Visit Date(s) for Information Requested*
The Purpose of this Record Disclosure is: (Check all that apply)*

Change of Insurance or PhysicianContinuation of CareReferralPersonal Records
How would you like these records released?*

MailedFaxedPickup in office
*
Date, Event, or Condition in which this authorization will expire:
(Optional)
I have read the above foregoing Authorization for Release of Medical Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization. I understand copy fees may apply.
Name of Patient:*

First NameLast Name
Name of Parent, Guardian or Authorized Representative: (IF NOT THE PATIENT):

First NameLast Name
Relationship to Patient
Phone Number of Parent, Guardian or Authorized Representative:

Area CodePhone Number
Date*

MonthDayYear
Date
Signature Name of Patient; OR Signature Name of Parent, Guardian or Authorized Representative:*

Clear
Records Fee*
prevnext( X )
Records Fee$20.00

Total $0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Authorization for McLean & Potomac Dermatology and Skincare Center to RELEASE Medical Information

I have read the above foregoing Authorization for Release of Medical Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization. I understand copy fees may apply.