Your privacy is important to us and we want to protect it as much as possible. By signing this form, you authorize Skin Care Doctors, P.A to disclose information as requested by the individual(s) you list below. This information may include, but is not limited to, verbal and written information relating to your diagnosis, treatment, and billing information.
Please complete, sign, and date this form. Be sure to include any individuals and/or specific details you may have listed previously, if appropriate, as any prior versions of this form will be inactive upon receipt of this completed form.
This authorization may be revoked at any time except to the extent that This authorization is valid until the following Skin Care Doctors, PA has taken action in reliance upon this authorization. Specified date or event, whichever is shorter. Revocation must be made in writing to Skin Care Doctors, PA, attn.: Privacy Officer at 14000 Nicollet Ave So, Suite 304, Burnsville, MN 55337.
I understand that Skin Care Doctors, PA will not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization. I also understand that I may be charged for copies of this information in accordance with state law.
Furthermore, I understand that if this information is disclosed to a third party, the information may be redisclosed by the person that receives the information and may no longer be protected by federal privacy regulations
ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form.
*If the patient is 18 years of age or older, the patient must sign and date the form.
*If the patient is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date the form. Please indicate your legal authority and include documentation of your relationship.
*If the patient is 17 years of age or younger, the patient’s parent or legal guardian must sign and date the form (unless an exception exists under state or federal law.
Burnsville Medical Center
14000 Nicollet Ave. South
Burnsville, MN 55337
Centennial Lakes Medical Center
7373 France Ave. South
Edina, MN 55435
Orono Professional Building
2765 Kelley Parkway
Orono, MN 55356
St. Cloud Office
1350 LeSauk Dr.
Sartell, MN 56377