Medical Records Request Form

I authorize:

NorCal Dermatology and Cosmetic

Khanh Truong, MD; Henry DeGroot, MD

196 Wikiup Drive

Santa Rosa, CA 95403

To release my medical records to:

All Medical Records

Specific Records Requested

I authorize:

To release my medical records to:

NorCal Dermatology and Cosmetic

Khanh Truong, MD; Henry DeGroot, MD

196 Wikiup Drive

Santa Rosa, CA 95403

Phone: 707-527-9917

Fax: 707-527-9913

All Medical Records

Specific Records Requested

This authorization is in effect now and will remain in effect until

I understand that I have the right to receive a copy of this authorization.

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.

Patient Name

D.O.B.

Patient Signature

Date

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