Authorization for Disclosure of Protected Health Information

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. On occasion, the patient and the Practice may want to use PHI for reasons other than treatment, payment, and health care operations, or for other purposes permitted by law. This form summarizes the anticipated use of information about you for which this authorization is required. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I hereby authorize FDL Dermatology, PLLC ("Practice") designated medical record custodians to use or to disclose (describe medical information to be disclosed)

to (identify person or facility to which described information is to be disclosed)

Health information used or disclosed pursuant to this authorization will be used or disclosed for (insert purpose or state "at request of individual" if request initiated by patient)

Expiration Date of this Authorization:

I understand that I may refuse to sign this Authorization and that Practice will not condition treatment on my agreeing to this authorization unless the sole reason for treatment is to create health information to be disclosed to a third-party, in which case, failure to sign this authorization may allow Practice to refuse to treat me or may prevent Practice from disclosing my health information to the intended third-party recipient.

I also understand that I will receive a copy of the signed Authorization.

I understand that information used or disclosed under this authorization might be re-disclosed by a recipient and may, as a result, no longer be protected to the same extent to which it is protected by law while solely in the possession of Practice.

This authorization will expire on the Expiration Date entered above (if no date specified, this Authorization will expire six (6) months after the date of signature shown below). However, I also understand that I have the right to revoke this authorization in writing at any time, except to the extent that Practice has already acted pursuant to the authorization. The written revocation should be sent to Practice at FDL Dermatology, PLLC, Attn: Privacy Officer, 1005 N Glebe Rd Ste 540, Arlington, VA, 22201 - 5718.

Patient Signature - This authorization was signed by:

Date

Legal Representative Signature (if applicable):

Date

Legal Representative Authority (if applicable):

Your information will be encrypted.