Authorization to Release Medical Information

Please correct the errors described below.

I hereby authorize (Indicate information on space provide below) to release medical information to the Skin Cancer & Dermatology Center of Colorado Springs. Release medical records to:

1975 Research Parkway, Suite 165, Colorado Springs, CO 80920 OR Faxed directly to: 719-574-6574

Information to be released: (Please check all boxes that apply)

The expiration date will be for one year unless otherwise noted. By signing below, I authorized the release of my medical information or the medical information relating to my child and/or minor for whom I am the legal guardian.

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.

Your information will be encrypted.