PH 843.837.4400 | FAX 843.837.4440

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

Carrie Hall, MD Dale Sarradet, MD Carmen Traywick, MD Joseph McGowan IV, MD Frank Zurfley, MD Audrey Green, MD Heather Casalicchio, PA-C Heather Cain, FNP-C Nicholas Cassel, PA-C Ansley Hiers, PA-C Jeffrey Kristan, PA-C Amanda Medlin, PA-C Kaylee Olszewski, PA-C Jonathan Samaha, PA-C Emily Simpson, PA-C

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

I have the right to revoke this authorization in writing except to the extent that May River Dermatology, LLC has acted in reliance upon this authorization. My written revocation must be submitted to May River Dermatology, LLC Compliance Officer, 350 Fording Island Rd., Suite 100, Bluffton, SC 29910. I further understand that my eligibility for health benefits, my enrollment in a health plan, and my treatment will not be affected by whether or not I sign this authorization.

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

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