Dates of service for requested release: All dates Date Range: Date to Date
I do do not 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 27302Fax: (919) 335-9032