Tricity Family Medicine & Urgent Care Clinic, PLLC

107 Hyannis Dr., Holly Spring, NC 27540
Ph: 919-363-8666 Fax: 919-363-8668

Authorization for Release Of Medical Information





  I authorize Tricity Family Medicine & Urgent Care Clinic to release
information to:
OR
  I authorize Tricity Family Medicine & Urgent Care Clinic to obtain
information from:


  Transfer of Care         Continuity of Care         Other   
  Immunization History         Laboratory test results         X-ray reports   
  All medical records related to a specific illness or injury.      
  Complete Medical Records

  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.

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