Phoenixville Dermatology Associates

Patient's Name

Date of Birth

Address

City

State

Zip

Phone

Date of Service

I authorize

to disclose the following records related to the date above.

Records

Entire Medical Record

Biopsy Reports

Diagnostic Records (lab, x-ray, etc.)

Office Notes from

Date to

Date

To include

HIV/STD

Drug and alcohol related

Please release these records to:

Name

Address

City

State

Zip

Phone Number

Fax Number

If Other, Please specify

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

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 Parent / Legal Guardian/Authorized Person

Relationship to Patient

Date

Your information will be encrypted.