AUTHORIZATION TO RELEASE AND/OR REQUEST MEDICAL RECORDS

AUTHORIZATION TO RELEASE AND/OR REQUEST MEDICAL RECORDS

WESTERN WAKE WELLNESS, PLLC
I authorize Western Wake Wellness to: *

Request From Disclose to
Name of Person or Facility: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone *
Fax
Email
The Protected Health Information of:
Patient Name: *

First Name Last Name
Chart #:
Date of Birth: *

Month Day Year
Phone *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Service: - HIDDEN TO PRESERVE DATA. REPLACED WITH OTHER FIELDS *

Month Day Year
Date of Service End: (If applicable) - HIDDEN TO PRESERVE DATA. REPLACED WITH OTHER FIELDS

Month Day Year
Dates of Records to be Released *

Last 2 Years of Records (Preferred) All Records (Due to size of chart, this section will likely have to be mailed) Specific Dates (enter below)
Start Date: Date* End Date: Date*
Service expires after:

Two Years
Check all that apply *

Office Visit Notes Labs/Pathology Health Summary Only Physician orders Patient Billing Records Other (Enter below)
If you selected other, please enter below:
Purpose of Request *

Personal Use Continued Patient Care Insurance Social Services/Disability Attorney/Legal
I UNDERSTAND THAT:

▪ I may revoke this Authorization at any time.

o The revocation will not apply to information that has already been released in response to this Authorization.

o I must revoke this Authorization in writing. The procedure for revoking this Authorization is to present my written revocation to the Front Office staff.

▪ I may refuse to sign this Authorization.

o My treatment, payment, enrollment in a health plan, or eligibility for benefits cannot be conditioned upon my authorization of this disclosure.

o A fee may be charged for providing the protected health information. Please contact our office to obtain fee and
rate information.

I understand that the information released may include sensitive information related to behavior and/or mental health, drugs and alcohol, HIV/AIDS and other communicable diseases, and genetic testing.

I have been informed and understand that information disclosed pursuant to this Authorization may be subject to redisclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no
longer be protected under federal medical privacy law.

Unless otherwise revoked, this authorization will expire on the following date, event, or condition:
Month Day Year
Optional
If I fail to specify an expiration date or event or condition, this authorization will expire automatically in one (1) year from the date of signature.

I have read and understand the information in this Authorization form.
Signature of Patient or Authorized Representative

Clear
Date

Month Day Year
Print Name of Patient or Authorized Representative *
Relationship to Patient *
Return records to Western Wake Wellness via fax at 919-239-4670 or by mail at:

Western Wake Wellness
401 Keisler Drive, Suite 101
Cary, NC 27518
Should be Empty: