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North Carolina Medical Records Release Form 2

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This form is provided to authorize the disclosure or release of one person's protected health information.

North Carolina Medical Records Release Form 2
North Carolina Medical Records Release Form 2
Metro Internal Medicine P.A.
Facsimile Transmittal Sheet
Dr Kenneth A. Holt, MD
3320 Executive Dr
Bldg E, Suite 222
Raleigh, NC 27609
Tel: 919.877.1100 Fax: 919.877.8118
AUTHORIZATION TO RELEASE MEDICAL RECORDS AND PATIENT INFORMATION
All sections must be completed.
Patient’s Name: _____________________________________________ Birthdate: ________________________
Street Address: _____________________________________________ Social Security #: __________________
City, State, Zip: _____________________________________________ Phone #: (home) ___________________
Maiden/Other Names: _________________________________________ (work) ___________________
I authorize Metro Internal Medicine (circle all that apply) to release / receive (circle one) information in my patient
records as directed below:
1. Name and address of person or organization to / from (circle one) whom disclosure is to be made:
Name: ______________________________________________________ Phone #: ______________________
Address (City, State, Zip): ______________________________________________________________________
2. Purpose of disclosure (please specify): ___________________________________________________________
(e.g., Patient’s request, Patient evaluation)
3. Dates of Service: From ________________________________ To ________________________________
4. Specific provider’s records to be disclosed: ____________________________________________________
(name of facility)
5. Revocation/Expiration. This authorization can be revoked in writing at any time unless the provider marked
above have already acted upon your request. All requests/instructions must be in writing, dated and signed.
6. Fees. There may be a fee associated with the processing of this request. Please check with the staff for
estimated costs. The providers marked above frequently contract with third party vendors for confidential record
copy services, so the bill for records copied may be generated by a third party vendor.
7. Important THE CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS ARE PROTECTED BY NORTH
Notice NORTH CAROLINA AND FEDERAL LAWS AND REGULATIONS. THE CONFIDENTIALITY LAWS AND
REGULATIONS PROHIBITED THE DISCLOSURE OF THESE RECORDS
UNLESS
:
1. THE PATIENT CONSENTS IN WRITING;
2. THE DISCLOSURE IS ALLOWED BY A COURT ORDER;
3. THE DISCLOSURE IS MADE TO MEDICAL PERSONNEL IN A MEDICAL EMERGENCY OR TO QUALIFIED PERSONNEL
FOR RESEARCH, AUDIT, OR PROGRAM EVALUATION. VIOLATION OF THE LAWS AND REGULATIONS IS A CRIME.
SUSPECTED VIOLATIONS MAY BE REPORTED TO APPROPRIATE AUTHORITIES IN ACCORDANCE WITH THE LAWS
AND REGULATIONS. FEDERAL LAWS AND REGULATIONS DO NOT PROTECT ANY INFORMATION ABOUT
SUSPECTED CHILD ABUSE OR NEGLECT FROM BEING REPORTED UNDER STATE LAW TO APPROPRIATE STATE OR
LOCAL AUTHORITIES.
My authorization to disclose the above information is voluntary, and the providers marked above will not condition the
provision of treatment on this authorization. I further understand that information disclosed pursuant to this
authorization may be subject to redisclosure by the recipient and is no longer protected by the laws and regulations
applicable to the providers marked above.
____________________________________________________________ _______________________________
Authority to Sign, if not the Patient Date
Copy to patient
Records to be: Mailed Faxed Picked up
North Carolina Medical Records Release Form 2