In order to assist you in receiving your health information from Indigo Dermatology,
please complete this form.

I authorize the
persons listed below to have access to any and all of my health information.
Indigo Dermatology is permitted to share my medical information with the
following people, including:
HIV, drug/alcohol abuse and psychiatric records, as well as test results and information disclosed during office visitsTest results and information disclosed during office visits not including HIV, drug/alcohol abuse and psychiatric records

Person 1

Full Name

Phone Number

Person 2

Full Name

Phone Number

Person 3

Full Name

Phone Number

We typically deliver benign biopsy results via phone call. If you do not pick up the
phone call, we request permission to leave your results on voicemail.

You may notify me or the parties listed above with
normal test results, appointment reminders and other information regarding my
health information as follows:

SelectMessage on cell voicemailMessage on Home Phone/# on file

I understand and direct that this authorization will remain in effect until it is revoked by me in writing.

Patient First Name

Patient M.I.

Patient Last Name

Patient Date of Birth (mm-dd-yyyy)

Signature

Date

Witness

QMC Patient Account

QMC Patient Account Date