Release of Medical Records
Complete this form to allow Family Care, PA to either release or receive your medical records. Please type your name, select your date of birth, enter the details of your release, sign your name, and hit Submit. For the "Other Facility" details, please provide the information for the person / facility involved in the transfer that is not Family Care. Fees may apply for paper copies of records, but electronic copies can be sent for free. Once you successfully complete the form, you will receive an email receipt and be transferred to a confirmation screen. Please call our office if you do not receive this confirmation, or if you have any questions. Thank you!
Patient Name
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First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date
Who do you want to SEND these records?
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Family Care
Click to type the name of the person / facility that will SEND these records.
Who do you want to RECEIVE these records?
*
Family Care
Myself
Click to type the name of the person / facility that will RECEIVE these records.
What is the REASON for your request to release medical records?
Please Select
Transferring PCP to Family Care.
Primary Care needs Specialist Notes.
Primary Care needs Hospital Notes.
Primary Care needs Lab Results.
Sending my records to a Specialist.
Sending my records to a Hospital.
Sending my records to a Surgeon.
Sending my records to a School.
Sending my records to a New PCP.
Requesting my own records by E-Mail.
Requesting my own records to Pick-Up.
Requesting my own records by USPS.
Other (Please Specify Below)
NOTE: If this field is not clickable on your computer, click into the previous question and hit TAB to make a selection using the arrows on your keyboard.
Which records would you like to be released? You may select more than one.
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Most Recent Office Visit & Labs (Default)
Most Recent Annual Wellness Exam
Most Recent Labs
Most Recent Hospital Notes
All Records (Last 3 Years)
All Records (Last 3 Months)
All Records for a Specific Diagnosis (Please Specify Below)
All Office Visit Notes
Other
Which records would you like to restrict from being released? (Do Not Send)
*
No Restrictions (Default)
Alcohol / Drug Abuse Notes
STD / HIV Results
Mental Health Records
All Lab Results
All Procedures
All Phone / Email / Portal Messages
Other
HOW do you want these records to be sent?
*
Fax (Default)
Email (Some Restrictions Apply)
In-Person Pick-Up
USPS Mail
Patient Portal
Other
The "Other Person / Facility" is the sender / recipient involved in this transfer that is not Family Care. What is the Other Person / Facility's PHONE NUMBER?
N/A for all incoming requests to Family Care.
What is the Other Person / Facility's FAX NUMBER?
Family Care's fax number is 919-361-2487.
What is the Other Person / Facility's EMAIL ADDRESS?
Family Care's email address is contact@familycarepa.com.
What is the Other Person / Facility's MAILING ADDRESS?
Family Care's mailing address is 1413 Carpenter Fletcher Rd, Durham, NC, 27713.
Standard processing time is generally 2 weeks for normal requests, 2 days for urgent requests, and 2 hours for desperate requests. If you require an alternate time frame for any reason, please call our office. How would you like to be notified when your request has been completed and your records have been sent?
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Patient Portal Message (Default)
Email
Phone Call
Do you have any notes for our staff that you'd like to add to this request?
I request that information about my healthcare and treatment be released as set forth on this form. This authorization covers all records that I have indicated above for release. This authorization covers information related to alcohol and drug abuse, mental health treatment, and sexually transmitted diseases, unless otherwise indicated. I have the right to revoke this authorization at any time by signing a written statement. This authorization will expire 365 days after the date I have signed below, unless otherwise indicated. I understand that this authorization is voluntary. I understand that a charge may apply for these medical records and may be payable to the facility that is releasing the information under NC Statute 90-411.
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Clear
Please verify that you are human
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Submit
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