AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

 

   __________________________                          ___________________________

    (Print Patients Full Name)                                           Birth Date(Mo/Day/Year)

 

   _______________________                                                  ___________________________

   (Street Address)                                                                   (Social Security Number)

 

   __________________                                   __________________________

      (City, State, Zip Code)                                   (Phone # Home)

 

At the request of the individual , I _______________________________, do hereby authorize

                                                       (Patients name)

__________________________________________________________ to release the followings:

         (Facility Name)

 

______Discharge Summary______________Pathology Reports________Emergency Reports

______History and Physical______________Laboratory Reports__________Immunization

______Progress Reports____________Radiology Reports__________Other

______Operative Reports___________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

________ I Do________ I DO Not    Psychiatric care and/or psychological assessment,

                                                               and treatment for alcohol or drug abuse.

 

INFORMATION RELEASE TO:                    Bunn Medical Center

                                                    ( Name of Company/Agent/Facility/Person)

                                                                    P.O.Box 368                                  

                                                               (street Address)

                                                                                Bunn, NC, 27508                                  

                                                             PHONE : 919 496 6511 , FAX 919 496 2889         

 

PURPOSE OF DISCLOSURE

 

______Referral to specialist   _____Insurance _______ workers Comp. _______ change Of Doctor

______Legal Investigation   ______Disability Determination _____Personal _____ Continuing care

 

Please provide daytime phone number in the event we need to contact you__________________

 

I hereby authorize disclosure of the health information for above named patient. This authorization is

valid for twelve (12) months from the date of signature. I understand that I may cancel this request

with written notification but that will not effect 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 or facility receiving it and would then no longer be protected by federal

regulations.

 

 

_______________________________                                      ___________________

Signature of individuals or guardian or                                      Date

Personal representative of patients state

 

*** Please note : There is a charge for medical records when requested for personal reasons, permanent

transfer , insurance purposes, legal purposes or disability purposes. ***