Aspen Dermatology AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATIONThis authorization is to release the protected health information of: Patient Name : First Last Date of Birth: MM slash DD slash YYYY Phone (HOME/MOBILE):Phone (WORK):Address: Street Address City State / Province / Region ZIP / Postal Code This authorization is to release protected health information FROM: Facility Name First Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFax Email This authorization is to release protected health information TO: Facility Name First Facility PhoneAddress* Street Address City State / Province / Region ZIP / Postal Code PhoneFax Email Please...* Mail record Email records Fax record The purpose of disclosure is:* Continuation of care Legal Patient’s personal use Other Other (Please List): Dates of service requested: Any and all date Specific date Choose Date MM slash DD slash YYYY Please release the following informaEon (check all that apply):* Select All History & Physical Operative Report Consultation Radiology Report Pathology Report Progress Notes Lab Report Medication Reports Other Other (Please List): RESTRICTIONS: Only medical records or informaBon originated through this healthcare facility will be released. This authorizaBon is valid only for the release of medical informaBon included within the dates specified by this authorizaBon. 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 wriUen revocation to the health information management department. I understand that the revocation will not apply to information that has already been released 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. 4.Unless otherwise revoked, this authorization will expire on the following date, event or condition: If I fail to specify an expiraBon date, event or condiBon, this authorizaBon 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 CFR 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. 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 Reset signature Signature locked. Reset to sign again If signed by Personal Representative, please list relationship to patient Δ
Aspen Dermatology & AestheticsAspen Dermatology & Aesthetics