AUTHORIZATION FOR RELEASE OF MEDICAL RECORD OR HEALTH INFORMATION Aspen Dermatology Authorization for release of medical record or health informationPatient Name* First Date of Birth MM slash DD slash YYYY Phone (HOME/MOBILE)Phone (WORK)Address Street Address City, State, Zip City State / Province / Region ZIP / Postal Code Above listed patient authorizes the following healthcare facility to make record disclosures (release from):Facility Name First Facility PhoneFacility Address Street Address Facility FaxCity, State, Zip City State / Province / Region ZIP / Postal Code The purpose of disclosure is: Change of Physician Continuation of Care Referral Other Other purpose of disclosure Dates of information to disclose Specific information requested RESTRICTIONS: Only medical records or information originated through this healthcare facility will be released. This authorization is valid only for the release of medical information included within the dates specified by this authorization. This information may be disclosed to the following individual or organization (to list more than one, request additional sheets): Release to Address Street Address City, State, Zip City State / Province / Region ZIP / Postal Code PhoneFaxEmail Disclosure information records Please verbally disclose records/information Please mail records Please email records Please fax records I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.Unless otherwise revoked, this authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this authorization will expire 1 year from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in DFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure, and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure. I have read the above foregoing Authorization for Release of information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.(Signature of Patient/ Parent/ Guardian or Authorized Representative -Please attache documentation of Authorized Representative status Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Printed name of Authorized Representative Relationship/Capacity to Patient Address and phone number or email of Authorized Representative Staff Initials Δ
Aspen Dermatology & AestheticsAspen Dermatology & Aesthetics