Medical History Request

REQUEST FOR HEALTH INFORMATION
AMERICAN SKIN INSTITUTE

4836 Van Nuys Blvd.

Sherman Oaks, CA 91403

Phone: (818) 907-7546

Fax: (818) 907-9506

Email: info@amskin.com

V.031824
Patient name:*

First Last
Patient date of birth:*

MMDDYY
Name of person requesting medical records:*

FirstLast
Phone number:*
Relationship:*

SelfParent / Legal guardianRepresentative with legal authorization to receive Protected Health Information (PHI)
ID/Driver's License card and/or proof of authorization for legal representation:*

PLEASE ATTACH IMAGE
Cancelof
Which records are you requesting:*

Office visit medical notesPathology reportsOperative/Procedure reportsHIV testsOther
Dates of service: Date* through Date*.
Who is being asked to release these records:*

American Skin InstituteOther (Enter address, fax and/or email)
Who will be the recipient of these records:*

American Skin InstituteOther (Enter name, address, fax, and/or email)
How would you like these records delivered:*

Paper: In-person pickupPaper: Home (Delivery)EmailFax
Expiration date:

MMDDYY
Signature:*

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Should be Empty:

REQUEST FOR HEALTH INFORMATION