Medical Records Release Authorization Form

Medical Records Release

Right to terminate or revoke authorization

You may revoke or terminate this authorization by submitting a written revocation to Sunnycoast Dermatology. You should contact the office to terminate this authorization.

Potential for Re-Disclosure

Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may be protected under federal privacy regulations.

Date

Records to be Released

TO: Persons authorized to use or disclose information

Information about the patient may be disclosed to:

FROM: Persons authorized to use or disclose information

Information about the patient may be disclosed by:

Expiration date of Authorization

This authorization is effective through the date below unless revoked or terminated by the patient or the patient's personal representative.

Patient Full Name

Date of Birth

Phone number

Signature of Patient

Date

Signature of Patient Representative

Date

Prefer to fill this out by hand? Download a blank copy to print and bring with you.

Download the blank Medical Release Form (PDF)