Authorization for release of medical information

Print blank form to fill by hand

For your convenience we have met all privacy requirements on a SSL secure server. Please fill the form and submit securely online, prior to your visit, assured that your privacy is maintained. We look forward to seeing you!

*Patient name :

*First name

Mid name

*Last name

*Your birthday :

*Telephone #:

()- -

E-mail :

*Home address :

City

State :

Zip :

APT# :

* I authorize the following Physician or Facility to release information:

Physician name :

Telephone #:

()- -

Fax #:

()- -

Address :

	City		State
	Zip

Please release Medical Records to :

AboutSkin Dermatology and DermSurgery, PC
5340 S. Quebec St., Ste. #300
Greenwood Village CO 80111
Telephone : 303-756-7546
Fax : 303-756-7547

Record to release :

All Records Physician Notes Lab Results HIV

*Patient Signature ( Patient/Patient Guardian ) :		Today’s Date :
**you will need to contact our office first, if you need your medical records to be released.