Release of Medical Records

Please correct the errors described below.

RELEASE OF MEDICAL INFORMATION

HERSCHEL E STOLLER, M.D.

CENTER OF DERMATOLOGY, P.C.

10110 NICHOLAS STREET, SUITE 103

OMAHA, NEBRASKA 68114-2185

(402) 398-9200 FAX (402) 398-9400

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.

Authorization Will Expire 90 Days From The Date Of The Patient Signature.

This Authorization Can Be Revoked At Any Time In Writing By The Patient Except In The Cases That The Medical Information Has Already Been Forwarded Prior To Receiving The Written Revocation.

Your information will be encrypted.

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