3rd Party Disclosure

BLUFFTON
7 ARLEY WAY, STE 101 | BLUFFTON, SC 29910
11 ARLEY WAY, STE 102 | BLUFTON, SC 29910
350 FORDING ISLAND RD, STE 100 | BLUFFTON, SC 29910

HILTON HEAD ISLAND
25 HOSPITAL CENTER COMMONS, STE 200 | HILTON HEAD, SC 29926

PORT ROYAL
1813 RICHMOND AVE | PORT ROYAL, SC 29935

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO THIRD PARTY

(Complete this form if you would like for May River Dermatology, LLC to disclose certain protected health information to family members)

I authorize May River Dermatology, LLC to use and/or disclose certain protected health information (PHI) as described herein. I understand that, if the person(s) or organization(s) that I authorize to receive my protected health information are not subject to federal and state health information privacy laws, subsequent disclosure by such person(s) or organization(s) may not be protected by those laws.

I authorize the following person (s) and/or organization(s) to receive my PHI, as disclosed by the person(s) and/or organizations(s) above.

Name(s) & Relationship(s)

Contact Telephone Number

Organization(s) & Address

Specific description of PHI that I authorize for disclosure (complete medical records, progress notes, labs, photos, etc.):

Specific description of the purpose for each use or disclosure (or write "At the request of the individual" in this space):

This authorization will expire on (date, event, or indefinite):

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO THIRD PARTY

I have had the opportunity to read and consider the contents of this authorization. I confirm that the contents are consistent with my direction.