AUTHORIZATIONtoRELEASEMedicalRecordsTOSeacoastDermatology,PLLC

SEACOASTDERMATOLOGY,PLLC330BorthwickAveSuite303Portsmouth,NH03801

17OldRollinsfordRdUnit1Dover,NH03820PH:(603)431-5205FAX:(603)436-4257

PatientName: DOB: Address: Phone: Iauthorize________________________________________toRELEASEmymedicalrecordsto:

SEACOASTDERMATOLOGY,PLLC330BorthwickAveSuite303Portsmouth,NH03801

FAX:(603)436-4257Pleaseprovideallpathologyreportsandofficevisitnotesfromthelastyearunlessrequestedotherwise.Duration(Ifmorethan1yearisrequested):

Iunderstandandacknowledgethatmymedicalrecordsmaycontaindrug/alcohol,mentalhealth,HIV,andorgenetictestinginformation.Icertifythatthisrequesthasbeenmadefreely,voluntarilyandwithoutcoercionandthattheinformationgivenaboveisaccurateandcompletetothebestofmyknowledge.Imayrefusetosignthisauthorizationbutmyrecordswillnotbesent.Ineednotsignthisforminordertoassuretreatment.IunderstandthatImayseeorcopytheinformationtobedisclosed.Imayrevokethisauthorizationinwriting,atanytimetotheextentthattheactionhasalreadybeentakentocomplywithit.Writtenrevocationiseffectiveuponreceipt.Re-disclosureofmymedicalrecordsbythosereceivingtheaboveauthorizedinformationmaybeaccomplishedwithoutmyfurtherwrittenauthorizationandmaynolongerbeprotected.Withoutmyexpressrevocation,theauthorizationwillexpireupondisclosureofrequestedinformationtotherequestedparty. SignatureofPatient(OR)PersonAuthorizedtosignforpatient Date

AUTHORIZATIONforSeacoastDermatology,PLLCtoRELEASEMedicalRecords

SEACOASTDERMATOLOGY,PLLC330BorthwickAveSuite303Portsmouth,NH03801

17OldRollinsfordRdUnit1Dover,NH03820PH:(603)431-5205FAX:(603)436-4257

PatientName: DOB: Address: Phone: Medicalrecordsareavailableforpatientstoview,downloadandprintfromthePatientPortalatwww.SeacoastDermNH.com.Ourofficecanhelpyoulog-inifyouhavenotyetdoneso.Youmayalsorequestthatrecordsbefaxedorpickedupfromourofficebyprovidingtheinformationbelow.Pleaseallowupto5businessdaysfortherequesttobeprocessed. IauthorizeSeacoastDermatology,PLLCtoFAXmymedicalrecordstoeithermyselforthe

healthcareprovider/hospitalbelow: Name: Fax#: Ichoosetopickupmymedicalrecordsfromyourofficeortosendanauthorizedagenttopick

themupforme.(Wewillcallyouwhentheyareready.) AuthorizedPickUpName: Phone: Wewillreleasepathologyreportsandofficevisitsnotesfromthelastyearunlessyourequestotherwise.Duration(Ifmorethan1yearisrequested):

Iunderstandandacknowledgethatmymedicalrecordsmaycontaindrug/alcohol,mentalhealth,HIV,andorgenetictestinginformation.Icertifythatthisrequesthasbeenmadefreely,voluntarilyandwithoutcoercionandthattheinformationgivenaboveisaccurateandcompletetothebestofmyknowledge.Imayrefusetosignthisauthorizationbutmyrecordswillnotbesent.Ineednotsignthisforminordertoassuretreatment.IunderstandthatImayseeorcopytheinformationtobedisclosed.Imayrevokethisauthorizationinwriting,atanytimetotheextentthattheactionhasalreadybeentakentocomplywithit.Writtenrevocationiseffectiveuponreceipt.Re-disclosureofmymedicalrecordsbythosereceivingtheaboveauthorizedinformationmaybeaccomplishedwithoutmyfurtherwrittenauthorizationandmaynolongerbeprotected.Withoutmyexpressrevocation,theauthorizationwillexpireupondisclosureofrequestedinformationtotherequestedparty. SignatureofPatient(OR)PersonAuthorizedtosignforpatient Date