• REQUEST FOR MEDICAL RECORDS TO BE SENT TO DIRECT PRIMARY CARE MEBANE

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  • Dates of service for requested release:  Date Range:   Pick a Date  to   Pick a Date   

  • I     authorize release of information related to AIDS, HIV infection, sexually transmitted diseases, psychiatric care and/or psychological assessment, and treatment for alcohol and/or drug abuse. 

    Revocation/Expiration: This authorization can be revoked at any time unless the provider named above has already acted on upon your request. All requests must be in writing, signed and dated. I understand that the information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected the federal privacy law. 

    Release information to: 
    Direct Primary Care Mebane 
    105 S. 4th St.
    Mebane, NC 27302
    Fax: (919) 335-9032

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