Ganger DermatologyConsent to Release Medical Information or Records I hereby Authorize(Required)Name of sending person, agency or institutionPatient Name(Required)To release to Ganger Dermatology, information pertaining to the care and treatment of: First Last Patient Date of Birth(Required) MM slash DD slash YYYY Patient Phone(Required)Patient Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Consent - Personal Information(Required) Disclosure is authorized for the following specific report(s)/information onlyConsent - Specific report(s)/information(Required) Disclosure is authorized for any and all information about medical history, mental and physical condition, including HIV infection, AIDS, or ARCD, drug and alcohol use, and other personal information.Consented Reports/informationThis authorization is valid from the date of signing unless revoked in writing by the undersignedSignature(Required)Signature of patient, or legal guardian signaturePrinted Name(Required)Name of the above signature First Last Patient outside records are processed in our Ann Arbor location. Please mail to the following address:1979 Huron Parkway Ann Arbor, MI 48104 Δ
