Records Release Form

Please complete and sign below to release your records.

Patient’s Name:

Date of Birth:

I hereby authorize and request that you release copies of my medical records concerning my illness and/or treatment at Cape Cod Dermatology, LLC to the following party:

Name:

Address:

Telephone:

Fax:

If there may be any sensitive information such as information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, mental health treatment, HIV testing and/or AIDS diagnosis or treatment in your medical record that you do not want released, please indicate below.

I understand that it is possible that Medical Records and information used or disclosed with my permission may be re-disclosed by a recipient and no longer protected by the HIPAA Privacy Standards. I understand that all records will be transmitted via secure fax. Requests to mail records will be subject to a fee based on volume. A copy of this authorization is as valid as the original.

Patient:

Date:

Your information will be encrypted.