Patient Name and Address

Enter Your Address

Certified Dermatology has my permission to release information contained in the medical record of the above-named patient.
Information requested (please be specific with dates if known):

Restrictions (if any):

Reason for Release:

Certified Dermatology will provide the information requested above to the following party (if applicable):
Release to

Release Attention of:

Release to address

I hereby authorize Certified Dermatology to release any medical information as requested above. This may include
information about drug or alcohol use, psychiatric, social work, or other protected information unless otherwise
excluded. I am aware that Certified Dermatology cannot control how the recipient uses or shares the information,
and that laws protecting its confidentiality at Certified Dermatology may or may not protect this information once
it has been disclosed to the recipient.
Information will not be released without a valid signature below. Copy fees may be associated with this request for
records. I can cancel this authorization in writing at any time, except to the extent that Certified Dermatology has
relied upon it. For example, if I cancel it after Dedicated Dermatology has sent requested records, Certified
Dermatology will not retrieve those records.

Authorized by

Date

Reationship to Patient