Medical Record Release

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Name:

Date of Birth:

Previous Name:

Social Security #:

I request and authorize Gardens Dermatology to release healthcare information of the patient named above to:

Name:

Address:

City, ST, Zip:

Phone:

Fax:

This request and authorization applies to:

Healthcare information relating to the following treatment, condition, or dates:

List:

Complete medical record

Other:

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

Signature:

Date:

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED

By signing above, I authorize the above named physician(s) or any staff to disclose, reveal, or open for inspection or observation, any report, statement, analysis, diagnosis or any record including mental, psychiatric, alcohol and drug abuse, and HIV records. I hereby release the above named physician(s) and staff from any restrictions imposed by law, in disclosing or revealing any professional record, observation or communication to the person(s) named.

Your information will be encrypted.