Tricity Family Medicine & Urgent Care Clinic, PLLC
107 Hyannis Dr., Holly Spring, NC 27540
Ph: 919-363-8666 Fax: 919-363-8668
1106 Parkside Main Street, Cary NC 27519
PH: 919-261-6446 Fax: 919-261-6448
Authorization for Release Of Medical Information
PATIENT'S NAME:
DATE OF BIRTH: (MM/DD/YYYY)
ADDRESS:
PATIENT’S PHONE# :
DATE OF REQUEST:
DATE NEEDED:
STAFF WITNESSED NAME:
SIGNATURE & DATE:
I authorize Tricity Family Medicine & Urgent Care Clinic to release
information to:
NAME OF PROVIDER OR FACILITY
ADDRESS
CITY STATE ZIP CODE
PHONE #/FAX # (INCLUDE AREA CODE)
OR
I authorize Tricity Family Medicine & Urgent Care Clinic to obtain
information from:
NAME OF PROVIDER OR FACILITY
ADDRESS
CITY STATE ZIP CODE
PHONE #/FAX # (INCLUDE AREA CODE)
PURPOSE FOR THIS REQUEST (Check one)
Transfer of Care
Continuity of Care
Other
TYPE OF RECORDS REQUESTED (Check one)
Immunization History
Laboratory test results
X-ray reports
All medical records related to a specific illness or injury.
Complete Medical Records
AUTHORIZATION VALID FOR: (Check one.)
This request only.
One year from the date of this authorization
OR
.(insert date.) This authorization applies to the records of the treatment received on or prior to the date of this authorization.
This request
and
for medical records of any
future
treatment of the type described above until:
I understand that:
My right to healthcare treatment is not conditioned on this authorization.
I may cancel this authorization at any time by submitting a
written
request to the address provided at the top of this form, except where a disclosure has already been made in reliance on my prior authorization.
If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations the information stated above could be redisclosed.
Release of HIV-related information mental health related care or substance abuse diagnosis and treatment information requires additional authorization.
There may be a charge for the requested records.
NOTE: Medical records are faxed in cases of medical necessity only.
Signature of Patient or Representative
Date
Relationship to Patient (if requester is not the patient)