Record Release Authorization for Use and Disclosure
Please correct the errors described below.
to disclose the following records related to the date above.
Please release these records to:
If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions, per your request, and no longer protected by these regulations
You may revoke this authorization in writing at any time by sending or faxing written notification to:
Phoenixville / Valley Forge Dermatology Associates 1260 Valley Forge Road, Suite 101 Phoenixville, PA 19460 Fax: 610-983-3406
Please note: Revocations do not apply to information that has already been disclosed or used before revocation has been received.
You have the right to receive a copy of this authorization. This authorization expires one year from date of signing or no
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