Stacia Poole MD, LLC Dermatology
Stacia Poole MD, LLCDermatology

Requests for Medical Records

HIPAA Authorization for Release of Records
2020-08-17 HIPAA auth for release of rec[...]
Adobe Acrobat document [75.5 KB]

Your medical records can be released only with your written consent.  Please begin the process by downloading and completing the above form, or by obtaining a similar form from your new doctor's office.  You may bring or mail the signed form to our office, or you may send a good quality photo or scanned image of the signed form to me via secure email by using the link :



We would like to complete records transfers electronically whenever possible, and there are several options to do this without charge.  


(1) If you designate a medical office to receive your records, we will make arrangements to securely transmit them to your new doctor on your behalf.  


If you would like to receive records yourself, 

(2)  You may activate the  "OnPatient"  patient portal provided by my practice by calling the office to request an email invitation.   To use the portal, we'll need to have your cell phone number, birth date and email address  on file;  once received,   simply click on the link in the email invitation and follow the directions to sign up for the OnPatient portal.  If convenient, an app is available for download, but you do not need to do so to use the portal - it can be accessed  here   or by clicking  the pink icon in the sidebar on this page.  Once signed up, your records can then be sent to the portal.  You will be notified by email when they are ready to view, print or download .  I anticipate that the patient portal will remain accessable through the end of this year but likely not into 2021, so please print or download records for your safekeeping beyond that time.  

(3)  Records can be sent to you by secure email.  The service I currently use is called "MailHippo".   In addition to the email containing your record,  a second email from "MailHippo" will be sent with a passphrase which is needed to "unlock" the main email so that you can download or print the chart.  ** The passphrase will only allow one time access to the email **; should you wish to have continued access, you will need to select the option to create a login to access the MailHippo portal.

(4)  If you have the capability to receive a fax, I am happy to fax your chart,  but please keep in mind that there may be many pages of records and some fax services charge a per page fee to receive data.


All of the above electronic records releases can be completed at no charge to you from my office.  If you need to have electronic files prepared on a flash drive or disc, that can be done for a $5 fee, plus applicable postage if mailing is required.


If you are not able to utilize an electronic option and must request paper records,  there will be a $5 charge for printing plus applicable postal fees.


After my office closes on November 30, record requests will be managed via the office of Dr. Jeannine Stein, who has graciously agreed to serve as my records custodian.    Her staff will coordinate with me to supply the necessary information until I ultimately turn over all records to her office for long term storage and access.   New requests after December 1, 2020 should be addressed to Dr.  Stein's office for processing.    Please contact her staff at:


                                                           The Center for Skin Cancer Surgery

                                                           7960 N. Wickham Rd, Suite 105

                                                           Melbourne, FL  32940

                                                           Ph. 321-428-4545 

                                                           Fax 321-421-7898       


Again, to request records you may utilize any formal medical records request form, either from you new doctor's office or downloaded from this site (use link above).  Please specify to whom the records should be provided, and list contact information (and fax number if possible) for your new doctor if they are not located in the Melbourne area.   Thank you.





Contact us

PO Box 360915

Melbourne, FL 32936 

Phone: 321-752-1599


Fax:  239-579-6774

Patient Portal

Click icon above for access to our patient portal.

Note: First time users please request an invitation to our portal by providing our office with your email address and cell phone number



Welcome to     Our Office



We are a small, single physician practice emphasizing personalized and patient-centered care.  Dr. Poole provides care for adult patients with skin cancer and other skin disorders with the support of her medical assistants, Anita and Kristie.  


Dr. Poole is board certified in Dermatology and in Internal Medicine, and has been in practice in Melbourne since 1993.

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