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Iowa City Dermatology 269 N. 1st. Ave Ste 100 Iowa City IA 52245 (319) 339-3872 (319) 339-3874 FAX

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient’s Name:

Date of Birth:

Street Address:

City, State, Zip:

I request and authorize Iowa City Dermatology, Erica Colleran, MD and or Susan Dale Wall, MD release healthcare information via electronic, paper or verbal about the patient named above to:

to

Name: Address: City:

State:

Zip Code:

This request and authorization applies to the following protected health information:  Healthcare information relating to the following treatment, condition, or dates:

 Dermatology Related only  Other: Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.

 Yes  No

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

Reason for Release

___ Moving out of area ___ Transferring Care ___ 2nd Opinion ___ Personal File ___ Legal ___ Insurance ___ Other

Patient Signature: Date Signed: This Authorization is voluntary. If I choose to cancel this consent at a later date, I must send written notification to the Practice Manager. If this consent is cancelled, I understand that information may have been released prior to the cancellation and that action would not be considered a breach of confidentiality. I also acknowledge that recipients of this information may possibly re-release the information without proper consent and once information is disclosed it may no longer be protected by federal privacy regulations. I understand I can review the disclosed information or ask questions to the Practice Manager. IC Dermatology PC does not require completion of this form as a condition for treatment, evaluation, payment or other health care operations. THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.


Release of info FROM icderm