Confidential Authorization for Release of Medical Records

Patient Name:

Date of Birth

I hereby authorize West Michigan Dermatology to:

Disclose Receive Exchange

Confidential information to, from, or with the following persons/organization:

Name of Organization:

Phone:

Fax:

Address:

Description of information to be disclosed:

ENTIRE PATIENT RECORD Office Notes Nursing Home, Home Health, Hospice & Other Physician Notes Lab Results / Pathology Reports Record of Mental Health or Substance Abuse Treatment Record of HIV & other Communicable Disease Testing Financial History (past 3 years)

This Release Covers a Period of One Year.

Expiration Date to be One Year From Completed Form

How would you like to receive your records?

FAX MAIL PICK UP IN PERSON EMAIL

Note: regular email is not secure and it is possible to compromise your PHI unless you are using an email that allows you to encrypt your email correspondence.

You have the right to revoke this authorization in writing at any time by sending such written notification to our office address. However, your revocation will not be effective to the extent that we have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to the authorization maybe subject to re-disclosure by the recipient of the information and no longer protected by the HIPAA Privacy Rule.

By initialing this form you are consenting to have your records disclosed, received or exchanged to the entity listed above

Initials:

Date

You have a right to receive a copy of signed authorizations upon request.

Your information will be encrypted.