HIPAA - Auth to Obtain Records

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

Month Day Year
Patient Phone Number

Area Code Phone Number
Sex
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

First Name Last Name
Name of Organization
If you are listing a medical practice, be sure to list your medical provider as well 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

Clear
Should be Empty:

Authorization for McLean Dermatology and Skincare Center to Obtain Medical Information from another Facility

Patient Information

Individual or Organization to which McLean Dermatology will release records