Release of Records Auth

RELEASE OF RECORDS AUTHORIZATION
Patient's Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
I authorize the release of my records from:

Holladay Dermatology & Aesthetics Robert B. Topham, MD and/or Sarah Forsey, PA-C
I authorize the release of

Medical records:
Medical records dated from:

MonthDayYear
Date
Medical records dated to:

MonthDayYear
Date
I authorize the release of:

Pathology/Lab reportsOther
Release this information to Company Name:*
Attention to (Doctor/Provider):*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
Fax:*
Please enter a valid phone number.
Patient/Guardian Signature:*

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Date*

MonthDayYear
Date
Should be Empty: