www.braundermatology.com - Medical Records Release Form

Medical Records Release Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*
(City, State / Zip Code)
I, or my authorized representative, request that health information regarding my care and treatment may be released as set forth on this form in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I fully understand the following:
- This authorization has no expiration date unless otherwise specified by myself or the authorized representative.
- Outside requests other than the patient, will be charged a fee of $55.00.
- Patient medical record requests will be charged a fee of $10.00. Medical records exceeding 20 pages will be charged an additional $0.10 per page.
- I may revoke this authorization at any time and must send such revocation to the Privacy Compliance Officer of the institution or medical practice responsible for the information I am requesting to be released.
- I understand that signing this authorization may be re-disclosed by the recipient, and this re-disclosure may no longer be protected by federal or state law.
- This information will be used for continuing medical treatment by the recipient physician, and/or for the purposes which I may request, as listed below:
Name and address of health provider or entity to release this information:

Braun Dermatology Associates Phone: 202-293-7618

3301 New Mexico Ave NW #301, Fax: 202-775-1772

Washington, DC 20016
Name and address of person, health provider, entity, or category of person to whom information will be released:
Name
Address
Phone:
Please enter a valid phone number.
Fax:
Specific information to be released:
Medical records from (date)
Date
To
Entire medical record (patient history, office notes, tests results, pathology reports, and photos)
Entire medical record, including: billing and insurance records, referrals, and consults
Other
(please specify)*
REASON FOR RELEASE OF INFORMATION
At request of individualContinuing medical diagnosis and treatmentOther
(please specify)*
Who Sign?*

I am PatientI am not a patient
If not patient, name of representative signing form*
Signature of patient or representative authorized by law*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Medical Records Release Form

Name and address of person, health provider, entity, or category of person to whom information will be released:

Specific information to be released:

REASON FOR RELEASE OF INFORMATION