Authorization to Release Healthcare Information

Patient's Name

Date of Birth

Phone #

Social Security #

Address

City

State

Zip

I authorize Lakeside Dermatology to release healthcare information of the (above named) patient to:

Doctor / Medical Office / Facility Name

Address

City

State

Zip

Phone

Fax

This request and authorization applies to:

Complete Medical Record

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

List below:

Other

List Below

Electronic Signature of Patient / Parent / Guardian

Date

DISCLAIMER: By signing 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.

DISCLAIMER: By signing above (electronically or in print), I am stating that I have the legal authorization to 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.