Tricity Family Medicine & Urgent Care Clinic, PLLC

DATE (MM/DD/YYYY)

RECORDS TO :

TRICITY FAMILY MEDICINE AND URGENT CARE CLINIC
107 HYANNIS DR
HOLLY SPRINGS NC 27540

  I request a copy of my complete medical record. (PLEASE DO NOT FAX, MAIL ONLY)

ACCEPT AND FILL   I request only the medical records from the time period

FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

PURPOSE OF RELEASE:

PATIENT'S NAME

DATE OF BIRTH (MM/DD/YYYY)

PATIENT'S SIGNATURE

WITNESSED BY

AUTHORIZATION FOR USE OF DISCLOSURE PROTECTED HEALTH INFORMATION

  I the above identified patient, or my legal representative, hereby authorizes use of disclosure of protected health information to/from TRI-CITY FAMILY MEDICINE & URGENT CARE CLINIC, PLLC including all records, x-rays, abstract and excerpt of all records, mental health records and/or evaluations and any other information which you may posses relating to the examination, diagnosis, prognosis, care & treatment, billing or opinion rendered concerning any and all conditions that the above identified PATIENT has had in the past, may have now & in the future. I understand that the information used or disclosed may be subject to re-disclosure by TRI-CITY FAMILY MEDICINE & URGENT CARE CLINIC, PLLC and would then no longer be protected by federal privacy regulations.