Cape Cod Dermatology, LLC - Records Release Form

134 ANSEL HALLET RD WEST YARMOUTH, MA 02675

508-771-9779
FAX:508-771-4355

Please fill out and electronically sign below.

RECORDS RELEASE FORM

TO: Cape Cod Dermatology, LLC

PATIENT:

DATE OF BIRTH:

I HEREBY AUTHORIZE AND REQUEST THAT YOU RELEASE COPIES OF MY MEDICAL RECORDS CONCERNING MY ILLNESS AND/OR TREATMENT TO:

Name:

Full Address:

Telephone Number

Fax Number

IF THERE ARE SPECIFIC CATEGORIES IN YOUR MEDICAL RECORD YOU DO NOT WANT RELEASED…….. PLEASE INDICATE:

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:

DATE:

Email address

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Cape Cod Dermatology, LLC - Records Release Form

RECORDS RELEASE FORM TO: Cape Cod Dermatology, LLC

RECORDS RELEASE FORM

TO: Cape Cod Dermatology, LLC