Spine and Pain Associates - Medical Release Form

Spine and Pain Associates

2304 Wesvill Court, Suite 320 Raleigh, NC 27607
T 919-825-3902
F 919-825-3910

1303 Carthage Street Spine & PainSanford, NC 27330
T 919-292-2468
F 919-292-2167
Request for Practice to Release Medical Records
Date

MonthDayYear
Date
First Name
Middle
Last
Date of Birth

MonthDayYear
Date
Address
City
State
Zip
Telephone: Home
Work
Cell
Email
example@example.com
I, (Name) blankshereby authorize Spine and Pain Associates, PLLC to release the following information:
Spine & Pain Associates, PLLC to release the following information

All RecordsConsultation NotesDischarge SummaryOffice VisitsHospital RecordsProcedure NotesEmergency Department RecordsSurgery/Operative ReportsPathology/Lab ReportsRadiology Reports (Ultrasounds, X-rays, MRI, CT scans)
Dates of Service for Requested Release

All DatesDate Range (Please use box below):
Please Send a Copy of my Medical Records to:
Physician/Provider Name
Medical Practice Name
Address
City
State
Zip
Fax Number
Spine & Pain Associates Request for Practice to Release Medical Records
Reason for Release:

Moving out of the areaTransfer of care/leaving the practiceEnsure continuity of care provided by your other providers (e.g. surgeon, primary care provider, physical therapist, rheumatologist, etc)PersonalLegalOther
Patient Name
Date

MonthDayYear
Date
Signature

Clear
Please note: For security reasons, Spine & Pain Associates, PLLC will either mail or fax your medical records as
requested. We will not send them by email.

Release of medical records takes 5-7 days for processing. There may be a $10 fee to cover the cost of staff time.
Additionally, if you request printed records then the cost will be:
• $10 for up to 25 pages
• Additional $0.25 per page for pages 26+

Copying Medical Records (in North Carolina)
Pages 1 - 25 $0.75 per page
Pages 26 - 100 $0.50 per page
Pages 100+ $0.25 per page
Minimum charge $10.00

Electronic Copy of Designated Record Set within Medical Records Requested Under HIPAA: $6.50
Should be Empty: