RELEASE FROM: (Name of Physician or Facility releasing information)
RELEASE TO: (Name of Physician or Facility receiving information)
I understand the Authorization may be revoked by written notice by myself at any time. Unless otherwise stated, this authorization will be in effect for one year past the date signed below. I understand that I may inspect and copy any written correspondence released to the above party. A photocopy of this authorization shall be fully effective and as valid for all purpose as the original hereof. I understand that once my PHI has been release it may not be covered under the Privacy rule of Cleaver Dermatology.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.