4447 South Canyon Rd, Ste. 6, Rapid City, SD, 57702

4447 South Canyon Rd, Ste. 6, Rapid City, SD, 57702

Medical Records Release

Photo identification will be requested for all hand carry release of information requests.

Name (printed) ______

D.O.B. ______

To: Fromm Dermatology – New Location

4447 S. Canyon Rd #6 Phone (605) 721-5550

Rapid City, SD 57702 Fax (605) 721-5515

From: Fromm Dermatology / Health Concepts

5410 Sheridan Lake Rd.

Rapid City, SD 57702

Phone (605) 721-5065

Fax (605) 721-7450 Physician: Dr. Linda Fromm

(605)-721-0321 Traci Hay, CNP

Any information including the diagnosis and records of my treatment or examination rendered to me during the time period from ( all Dermatology Records ).

Signature ______Date ______

This authorization expires one year from the date of signature unless revoked in writing prior to expiration date. I understand that I may revoke this authorization at any time by notifying Fromm Dermatology in writing, but if I do, it will not have any effect on actions taken before the revocation was received.