Medical Records Release Form

Please correct the errors described below.

to release information concerning the patient identified above in accordance with state and federal laws, to Access Dermatology, PC, 563-A Neff Avenue, Harrisonburg, VA 22801, (540) 434-1756 (phone) or 540-434-1840 ( HIPAA Secure Fax).

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.