Download Recods Release Form

North Carolina Center for Reproductive Medicine, P.A.
400 Ashville Avenue, Suite 200, Cary, NC 27518
Phone: 919-233-1680 Fax: 919-233-1685
Authorization for Release of Medical Information
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Print patient’s full name! !
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Street Address!
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City, State, Zip Code!
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Birth Date (Month/Date/Year)
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Social Security Number
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Phone (Home)
At the request of the individual, I____________________________ do hereby authorize
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Patient’s name
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Name of Facility!
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Address of Facility
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Phone # of Facility ! !
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Fax # of Facility
_____ Discharge Summary _____ Pathology Reports _____ Emergency Reports
_____ History & Physical
_____ Laboratory Reports _____ Other
_____ Progress Notes
_____ Radiology Reports
_____ Operative Notes
_____ ECG/EEG/Cardiac Cath ____________________
_____ _________________
From the time period of ____________________ to __________________________
_____ I do _____ I do NOT authorize release of information related to AIDS (Acquired
Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) Infection,
psychiatric care and/or psychological assessment and treatment for alcohol and/or drug
abuse.
Mail Information to:
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NCCRM ~ 400 Ashville Ave. Suite 200 Cary, NC 27518
Attention: Medical Records
_____ Referral to Specialist _____ Insurance _____ Worker’s Comp
_____ Change of Doctor _____Legal Investigation _____ Disability Determination
_____ Personal _____ Continuing Care _____ Other: specify_____________________
I hereby authorize disclosure of the health information for the above named patient.
This authorization is valid for 12 months form the date of signature. I understand that I
may cancel this request with written notification but that it will not affect any information
released prior to notification of cancellation. I understand that the information used or
disclosed may be subject to re-disclosure by the person or class of persons of facility
receiving it and would then no longer be protected by federal regulations. I understand
that the medical provider to whom this is authorized is furnished may not condition its
treatment of me on whether or not I sign the authorization.
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Signature of individual or guardian or personal! !
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Date
representative of patient’s estate
Please note: There may be a charge for records from your current physician’s office.
Entire _____ Lab _____ Mammogram_____
Health Report ROI Specialist
IMM _____ EKG _____ Number of Pages ______
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PN
_____ X-Ray _____ Other ___________
PL/MEDS_______ PATH ________
Date _________________________