Record Request Form

Name:

Date of Birth:

Address:

City:

State:

Zip:

Phone:

Last 4 of SSN#:

do hereby authorize the release of:

Entire Chart

Progress Notes

Pathology Reports

Lab Reports/Results

Release Records From:

Highlands Dermatology, P.A
5526 Cashiers Road
Highlands, NC 28741

Phone: (888) 565-8828 Fax: 1-828-414-1639 (Please dial 1+828 and then fax #)

Release Records To:

Name:

Address:

City:

State:

Zip:

Phone:

Fax:

Purpose of Disclosure:

Referral to specialist

Insurance

Primary Care Physician

Self

Other

I hereby authorize disclosure of the above named patient. This authorization is valid until I revoke it in writing and will not take any effect on any information released prior to notification of cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person/class of persons/facility receiving it and would not longer be protected by federal regulations. I understand that the medical provider to whom this information is furnished may not condition their treatment of me whether or not I sign the authorization.

Signature of patient or legal representative

Date:

Your information will be encrypted.