Medical Records Release of Information Request - Transferring Out

Please correct the errors described below.

By signing below, I further certify that I understand email copies and flash drives are not encrypted and may not be secure. I understand that I am responsible for providing a correct fax number or email address. I understand that printed copies belong to me, and Acces Dermatology, P.C. is no longer responsible for the privacy of copies I take once they leave the office ( to include in transit to the post office or while in the mail). I accept responsibility for securing my private medical information whether it is received in printed or electronic forms.

I request the medical records in the following format:

Your information will be encrypted.

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