Patient Authorization Form

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouses, significant other, parents, or children to call and request the result of tests, procedures, and financial info. Under the requirements for HIPAA, we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical information, any diagnostic test results, and/or financial information released to any family members you must sign this form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

I authorize Sonoma & Napa Valley Dermatology to release my records and any information requested to the following individuals.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.