Record Release Authorization for Use and Disclosure
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
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.
Your information will be encrypted.