EmailMeForm
MEDICAL RELEASE CONSENT
SOUTHEASTERN DERMATOLOGY GROUP, P.A.
Dermatology Specialists of Alabama, Florida, Georgia, Mississippi
PHONE: 877-231-DERM (3376) - FAX: 850-522-8354
EMAIL: medicalrecords@dermsolutionsgroup.com
(Complete all sections to prevent delays. Allow up to 14 business days for request to be processed.)
Patient Legal Name
First
Last
Date of Birth
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YYYY
Social Security Number
Phone
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Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
For Disclosure Only
I hereby authorize
Name of physician and/or Practice Name to Release Records
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Telephone Number
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Fax Number
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To disclose medical record information and/or protected health information of the patient listed above to:
Name of Physician and/or Practice Name/Individual/Organization to Receive Records
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Telephone Number
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Fax Number
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Purpose
Type of Access Requested:
Copies of the record
Inspection of the record
Entire Record
Select Portions of Personal Health Information:
Emergency Room
History & Physical
Consult Report
Operative Report
Lab
Imaging/Radiology
Demographics
Progress Note
Medication Record
Path Report
Physician Orders
Billing Records
Other
Expiration: This authorization shall expire in one year unless otherwise specified below:
Fulfillment of this request (according to HIPAA or State Regulations, whichever is shorter)
Date (not to exceed one year)
I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information. I understand that this authorization may be revoked by me at any time except to the extent that action has been taken in reliance upon it.
The information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected.
Fees/changes will comply with all laws and regulations applicable to release of information. Power of Attorney (POA) must be attached if signing as POA.
Date
MM
/
DD
/
YYYY
Signature
Clear
Signature of Patient/Responsible Party
Relationship to Patient
Address of Requestor (if different from the patient information)
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Telephone number of Requestor (if different from the patient information)
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