Medical Records Release Form "*" indicates required fields Patient InformationPatient Full Name* First Last Date of Birth* MM slash DD slash YYYY Phone*Your Email* Records Release InformationRelease Records To:*Enter the Physician/Person/Facility/Entity where you want your records releasedAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Fax #Email Medical Records Release Agreement*I grant Skin Health Forever Dermatology permission to release my private health information to the party listed above, by providing a copy of my medical records, laboratory/pathology results, billing records, prescription history, and all other records related. I agree to allow Skin Health Forever to records release my records to the party listed above.Signature*Name* First Last Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
