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

REQUEST FOR MEDICAL RECORDS TO BE SENT TO DIRECT PRIMARY CARE MEBANE
Date:

MonthDayYear
Date
Medical Record Number
(to be filled in by the practice):
Patient Name:
Date of Birth:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Name and location of the facility who will release the information:
Phone:
Please enter a valid phone number.
Fax:
Records requested:

All RecordsConsultation NotesOffice VisitsDischarge SummarySurgery/Operative ReportsEmergency Department RecordsPathology Lab ReportsHospital RecordsRadiology Report (Ultrasound, MRI, Cat Scan, DI)
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 27302
Fax: (919) 335-9032
Print name:

First NameLast Name
Signature:

Clear
Should be Empty: