Authorization for Disclosure of Medical Records

Patient's Name

Date of Birth

SSN #

Address

City

State

Zip

Phone

RELEASE FROM: (Name of Physician or Facility releasing information)

I authorize release of my medical records from

Physician/Facility

Phone #

Address

City

State

Zip

Fax

RELEASE TO: (Name of Physician or Facility receiving information)

Please send my medical records to

Physician/Facility

Phone #

Address

City

State

Zip

Fax

RELEASE INFORMATION

Reasons

Change of Insurance

Transfer of Care

Personal File

Moving out of area

Specialist Consult

Legal

Please Release the following: (Check all that apply)

Entire Record

Lab/Pathology Results Only

X-Ray Reports

Last Visit

Other

Date

If other, Please specify

CONSENT

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.

Signature of Patient

Date

Signature of Witness

Date

Your information will be encrypted.

Authorization for Disclosure of Medical Records

RELEASE FROM: (Name of Physician or Facility releasing information)

RELEASE TO: (Name of Physician or Facility receiving information)

RELEASE INFORMATION

CONSENT

CLEAVER DERMATOLOGY