REQUEST FOR DIRECT PRIMARY CARE MEBANE TO RELEASE MEDICAL RECORDS

REQUEST FOR DIRECT PRIMARY CARE MEBANE TO RELEASE MEDICAL RECORDS
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Record Number
(to be filled in by practice):
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
I, (NAME) ____________, hereby authorize Direct Primary Care Mebane to release the following information:
Dates of service for requested release:
All dates
Date Range: Date to Date
Please send a copy of my medical records to:

Cancelof
Physician Name:
Medical Practice Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number:
Will you be returning to Direct Primary Care Mebane?
Reason for Release:

Other
Revocation/Expiration: This authorization can be revoked at any time unless the provider named above has already acted on upon your request. All requests must be in writing, signed and dated. I understand that the information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected the federal privacy law.
Print Name:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature:
Please note: For security reasons, Direct Primary Care Mebane will mail or fax your medical records as requested. We will not send them by email.

Release of medical records takes 7-10 days for processing. There is a $10 fee to cover the cost of staff time.

Copying Medical Records (in North Carolina):
- $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: