AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

I authorize and request

to release to following noted protected health information from the medical records of the patients listed above to

To be mailed/faxed to

By electronic access to medical and claims information
Through oral communication with healthcare providers regarding treatment, care or payment.

The specific information for the following dates of service

INFORMATION TO BE DISCLOSED:

Entire Record
Laboratory Reports
Operative Reports
History and Physical (e.g., Doctor Visit)
Other

If other, please specify.

Expiration date of this authorization

The above mentioned Protected Health Information may be subject to re-disclosure by the party receiving the information and may no longer be protected by the privacy laws. To the extent that this form authorizes the sale of your Protected Health Information, such as a disclosure will result in remuneration to the practice. By signing this form, you authorize Calais Dermatology Associates to use and disclose Protected Health Information about you for the reasons mentioned above. You have the right to revoke this authorization at any time. However, such a revocation shall not affect any disclosure we have already made in reliance on your prior authorization. Submit your revocation to the Privacy Officer.

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 of Patient or Legal Representative

Date

Relationship to Patient

Signature of Witness

Your information will be encrypted.