Release of Electronic Medical Records for Treatment Purposes. I authorize the electronic release of medical records information, and I specifically authorize the release of all information concerning treatment relating to HIV testing, AIDS or AIDS related condition, and/or treatment of mental health or psychiatric condition(s), to other health care providers who utilize an electronic medical record system compatible with the Certified Dermatologists records system only for the purposes of providing treatment to me, or the patient named below. The authorization provided in this section will expire one year after the date of discharge. I am aware that I can revoke, in writing, this authorization at any time except to the extent that action has been taken in reliance thereon. I understand that if I refuse or revoke this authorization Cerfified Dermatologists will not deny any treatment to me or the patient named below.
Release of Electronic Medical Records for Treatment Purposes. I authorize the electronic release of medical records informaﳳon, and I specifically authorize the release of all informaﳳon concerning treatment relaﳳng to HIV tesﳳng, AIDS or AIDS related condiﳳon, and/or treatment of mental health or psychiatric condiﳳon(s), to other health care providers who uﳳlize an electronic medical record system compaﳳble with the Cerﳳfied Dermatologists records system only for the purposes of providing treatment to me, or the paﳳent named below. The authorizaﳳon provided in this secﳳon will expire one year aꓵer the date of discharge. I am aware that I can revoke, in wriﳳng, this authorizaﳳon at any ﳳme except to the extent that acﳳon has been taken in reliance thereon. I understand that if I refuse or revoke this authorizaﳳon Cerfified Dermatologists will not deny any treatment to me or the paﳳent named below.
Release of Electronic Medical Records for Treatment Purposes. I authorize the electronic release of medical records information, and I specifically authorize the release of all information concerning treatment relating to HIV testing, AIDS or AIDS related condition, and/or treatment of mental health or psychiatric condition(s), to other healthcare providers who utilize an electronic medical record system compatible with the UC Health records system only for the purposes of providing treatment to me, or the patient named below. The authorization provided in this section will expire one year after the date of discharge. I am aware that I can revoke, in writing, this authorization at any time except to the extent that action has been taken in reliance thereon. I understand that if I refuse or revoke this authorization, UC Health will not deny any treatment to me or the patient named below.
