Madison Skin _ Laser Center

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					                         Madison Skin & Laser Center
                            Brandith Irwin, MD Rebecca Patton PA-C
                          1101 Madison St., Ste. 1490 Seattle, WA 98104
                             (206) 215-6600 phone (206) 215-6650 fax

                AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Patient’s Name: ______________________________                  Date of Birth: ____________________________

SSN: _______________________________________                    Previous Name: __________________________

Address: ____________________________________                   City/ State: _____________________________

Zip Code: ___________________________________                   Phone #:________________________________

I. My Authorization:
This request and authorization applies to: (Check One)
_________ Health care information relating to: DERMATOLOGY AND PATHOLOGY
_________ All health care information
_________ Other: ________________________________________________________

I request and authorize:
                 Name: ______________________________________________________________

                  Address: ____________________________________________________________

                  City/State: _________________________________ Zip code: ________________

To release heath care information of the patient named above to:

                  Name: ______________________________________________________________
                                         (Institutional Affiliation)
                  Address: ____________________________________________________________

                  City/State: ___________________________________ Zip code: ______________

Purpose or need for this information __________________________________________________

II. My Rights
I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or
enrollment).
However, I do have to sign an authorization form:
      To take part in a research study or to receive health care when the purpose it to create health care
         information for a third party. I understand that information used or disclosed pursuant to this
         authorization may be disclosed to the recipient and may no longer be protected by federal or state law. I
         may revoke this authorization in writing. If I did it would not affect any actions already taken by
         Madison Skin & Laser Center based upon this authorization. I may not be able to revoke this
         authorization if its purpose was to obtain insurance. To revoke this authorization, I must write a letter to
         Madison Skin & Laser Center records release department.

Madison Skin & Laser Center keeps a record of health care services provided to you. You may examine and/or
request a copy of your record. You may also ask to correct that record. Your records will not be released to other
unless directed by your or compelled by law to do so.


Signature of patient or patient’s authorized representative                        Date Signed

___________________________________________________________________________________
Relationship or status if signed by anyone other than patient    Date Signed

              THIS AUTHORIZATION EXPIRES 90 DAYS AFTER THE DATE IS SIGNED

				
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