Helendale Dermatology & Medical Spa 500 Helendale Road, Suite 100 Rochester, NY 14609 585.266.5420 fax 585.266.5423 Authorization for Use and Disclosure of Protected Health Information

This form provides authorization to Helendale Dermatology & Medical Spa to use or disclose certain of your personal health information for the purpose(s) described below. It is intended to properly inform you of how this information will be used or disclosed. You should carefully read the information on this form before signing it.

(if left blank, 2 years of medical history and all pathologies are provided)

The disclosure of any part of the medical record deemed to be “psychotherapy notes” will require a separate authorization. I understand that if my records contain information about alcohol and drug abuse, mental health treatment and/or HIV/AIDS status, I authorize the Practice to release such information as part of my medical record only if I place my initials on the appropriate line as set forth below

(if left blank, it will expire when records are sent)

I understand that I have the right to revoke this authorization at any time, in writing, by mailing such written notification to the Practice’s Privacy Officer, at Helendale Dermatology & Medical Spa, 500 Helendale Road, Suite 100, Rochester, New York 14609
I understand that a revocation is not effective to the extent that the Helendale Dermatology has taken action in reliance on this authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the law provides the insurer with the right to contest a claim under the policy or to contest the policy itself.
I understand that Helendale Dermatology will not condition my treatment on whether I provide authorization for the requested use or disclosure if to do so would be prohibited by federal or state law. If a reason exists under law for conditioning my treatment on obtaining this authorization, I have been advised of that fact and of the consequences of me refusing to sign this authorization. I understand there is the potential for information used or disclosed pursuant to this authorization to be subject to re-disclosure by the recipient if the recipient is not required by law to protect the privacy of the information. I understand that I will receive a copy of this authorization if signed by me.
I hereby authorize the use or disclosure of my health information as described in this form.

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We’re located at 500 Helendale Rd in Rochester, NY and open Monday through Saturday.

Feel free to call us at 585-266-5420 during regular hours, or write to us confidentially through our website’s secure contact page.