Authorization for McLean Dermatology and Skincare Center to Obtain Medical Information from another Facility
Patient Information
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
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Patient Phone Number
*
-
Area Code
Phone Number
Sex
*
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Individual or Organization to which McLean Dermatology will Release Records
The above-mentioned patient or his/her parent/legal guardian authorizes McLean Dermatology and Skincare Center, located at 6849 Old Dominion Drive, Suite 450, McLean, VA 22101, to obtain medical record information from the following individual or facility:
Name of Individual to which McLean Dermatology will Release Records
*
First Name
Last Name
Name of Organization
*
If you are listing a medical practice, be sure to list your medical provider under name of individual
Phone Number
*
-
Area Code
Phone Number
Fax Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Information to Disclose
*
Entire Record
Pathology Results Only
Blood or Culture Test Results Only
Receipts and Billing Information Only
Specific Visit notes and/or Test Tesults
Visit Date(s) for Information Requested
*
The Purpose of this Record Disclosure is: (Check all that apply)
*
Change of Insurance or Physician
Continuation of Care
Referral
Personal Records
How would you like these records released?
*
Mailed
Faxed
Pickup in office
Authorization for Release of Medical Information. By signing this form you acknowledge that you are familiar with and fully understand the terms and conditions of this authorization, and that copy fees may apply.
*
Date, Event, or Condition in which this authorization will expire:
(Optional)
Name of Individual Completing this Form
*
First Name
Last Name
Relationship to Patient
*
Contact Number of Individual Completing this Form
*
-
Area Code
Phone Number
Signature
*
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