MEDICAL RECORDS RELEASE FORM

Request for Access to Medical Information

Our Notice of Privacy Practices provides information about our use of a patient's protected health information. The Notice contains a Patients Rights section describing your rights under the law. Patients have the right to access, inspect, and copy protected health care information used to make decisions about them.

The Practice will only include information used to make decisions about the patient. The Practice may limit access to information generated only by this Practice. Under some circumstances, such as increased risk or harm or injury, the Practice may withhold the requested information. The Privacy Officer of this Practice will evaluate this Request and notify the patient of our decision within fifteen (15) days of this Request. If the Request is approved, the Practice will provide the information within thirty (30) days or within sixty (60) days if such an extension is necessary. Reasonable costs will be charged for this Request. Costs will be submitted to the patient upon approval of the Request. The Practice may provide a summary of the requested information if you are agreeable.

The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Patient Name:

Include DOB

Health Care Information requested. Please provide dates, diagnosis, treatment, or any other indications of the specific information you desire:

Reason for requesting records:

Insurance - Out of network

New dermatologist

Other

If other, please specify

Is a summary of the information acceptable?

Do you wish to:

Arrange an appointment to inspect the requested information?

Receive a copy of the information?

Instructions regarding copies:

I will pick the copies

Please mail the copies to me at the following address:

This Request was signed by:

Relationship to Patient (if other than patient):

Date:

By typing your name above, 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.