Release For Medical Records Apr 22, 2020 Name AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Today's Date * Patient Date Of Birth * First Name * Middle Initial Last Name * Previous Name (if applicable) Email Address * Home Number * Work Number Cell Number SSN * I request and authorize SENTER DERMATOLOGY to Release To Receive From Name Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code The health care information on the above mentioned patient. If this request and authorization applies to specific dates of service, please specify the date range below. From To This request and authorization applies to Complete medical record Pathology and/or laboratory reports Other Relation To Patient * ********** THIS AUTHORIZATION EXPIRES 1 YEAR AFTER IT IS SIGNED**********
