• Authorization for Release of Medical Record Information

  • Patient Information

  • Outside Provider or Individual Information

    The organization or person that is to obtain/release records
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  • Details of Release of Information

  • Dates of Treatment covered by this ROI (if known):

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  • Section 3: I understand that the information or records sent to West Cary Psychiatry may be incorporated into my medical record and will become part of my protected health information at West Cary Psychiatry. I understand that my treatment at West Cary Psychiatry will not be conditioned on whether or not I sign this authorization.

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  • Clear
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  • Should be Empty: