Medical Records Release

Authorization of Disclosure of Health Information
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I hereby authorize Vital Dermatology, LLC to release my Protected Health Information (PHI) to the person(s) indicated. I understand that such disclosures may include, but not be limited to, discussing my medical care including sensitive information such as alcohol abuse, drug abuse, mental health disorders, confidential HIV related information, appointment scheduling specifics and billing details. I understand that I may revoke this authorization in writing at any time.

I HEREBY CONSENT AND AUTHORIZE MY VITAL DERMATOLOGY TO RELEASE PHI TO THE AUTHORIZED PERSON(S) LISTED BELOW:

Authorization of Disclosure of Health Information