Patient Consent Form

    AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

    1. My Information

    Patient Name

    Date of Birth

    Patient Address

    Patient # (if applicable)

    2. My Physician's Information

    Physician Name

    Physician Address

    3. Health Information

    Describe Health Information to be Disclosed

    4. My Authorization

    I authorize my Physician to use and disclose the Health Information for the purposes described below, subject to the terms of this Authorization.

    5. Purpose of the Disclosure

    My Physician may disclose the Health Information by publishing or posting it on Dermpedia, which is a web site used by health professionals for purposes of education and research. In addition, my physician may disclose the Health Information for the following purposes:

    Describe Other Purpose of Disclosure (if any)

    6. Information About My Rights

    I understand and confirm that:

    • I am not required to sign this authorization to receive care from my Physician.
    • I may request a copy of this signed authorization.
    • This authorization will not expire and will continue until I revoke it.
    • I may revoke this authorization at any time by sending a written request to my Physician; however, the revocation will not have any affect on any actions my Physician took prior to receiving the revocation. In particular, my Physician will not be required to remove any posting on Dermpedia that contains the Health Information that was made prior to the date my Physician receives my revocation.
    • My physician has described to me the nature of the posting he or she intends to make on Dermpedia and I have had an opportunity to review any photographs or other images that will be included in the posting, and I give my permission for them to appear on Dermpedia.
    • My Physician will not disclose my name, and will use reasonable efforts to ensure my anonymity, but I recognize that it is possible that someone will be able to identify me based on the Health Information.
    • Although Dermpedia is intended for use by health professionals, other persons may be able to access the Health Information on Dermpedia.
    • The Health Information may no longer be protected by federal privacy regulations once it is posted on Dermpedia.

    7. My Signature

    My Signature

    Date