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Welcome to Bergen Dermatology Specialists

We look forward to seeing you for your visit.

Please fill out the electronic form below.
If you don’t want to fill out this form electronically, click here to print a PDF version and fill it out prior to your appointment.
Thank you.

Patient Information

First Name*

M.I.

Last Name*

Date of Birth* (mm-dd-yyyy)

Phone*

Address

Street*

City*

State*

Zip*

TO: (Who are the records going to? Fill out completely.)

Name*

Phone*

Fax (for patient care only)

Address

Street*

City*

State*

Zip*

FROM: (Where are the records coming from? Fill out completely.)

From Bergen Dermatology Specialists

Name*

Phone*

Fax (for patient care only)

Address

Street*

City*

State*

Zip*

Information to be Released (What information and/or dates do you want released?)

Date(s) of Service for the records*

Type of records for release*

Instructions for Release (How and when is the information needed?)

Information Due Date* (Allow 7 business days for completion)

Information Release Method*

Purpose of Release (Why is the information needed?)

Purpose of Release*

* Fees may be charged in accordance with NJ Statute NJAC 8: 43G- 15.3 and Federal Rule 45 C.F.R §164.524

This authorization lasts for one year after the date of signature unless you enter a different date of expiration:

This authorization may be canceled in writing at any time.

Bergen Dermatology Specialists will not restrict treatment if you choose not to sign this authorization.

Your records will be released once the fee is received. You can call the office on 201-652-4536 to pay by phone, pay online on the website (Click Here), or send a check to the office.

A copy of this authorization will be treated in the same way as the original.

Bergen Dermatology Specialists cannot prevent redisclosure of your information by the entity who receives your records under this authorization and your information may no longer be protected by the Federal HIPAA Privacy Rule after release.

Your signature indicates that you have read and understand this form and authorizes the release of your information as indicated above.

Signature of

Signature

Date

If you are electronically signing this document, check the box below. By checking this box, I understand my electronic signature is valid and legally equivalent to manually/handwritten signing.

Authority to act on behalf of patients (attach document) (You can attach up to 10MB png, jpg, jpeg or pdf file)

When you submit, your form will be sent to a HIPAA secure account.