Authorization for the Release of Medical Records

Carolina Spine Center Phone: Rockingham: 910-997-3733 Raleigh: 919-948-6877
Cary: 919-436-4277 | Fax: 910-997-3707

Authorization for the
Release of Medical Records
Name*

First NameMiddle InitialLast Name
Provider Location*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Phone #*

Country CodeArea CodePhone Number
Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State*
Zip*
I hereby request that my medical records, as indicated below, be released to Carolina Spine Center for the continuation of patient care:
Persons/Organization providing information*
Paul Singh M.D.Neema Patel FNPJohn Schmidt M.D.Christie Dixon FNPPeng Bai D.O.Louis Torres M.D.Kim Puckett FNPAll Providers
Rockingham: 809 S. Long Drive, Suite G. Rockingham, NC 28379Raleigh: 3001 Edwards Mill Road, Second Floor West, Raleigh NC 27612Cary: 100 Parkway Office Court, Suite 108 Cary NC, 27518
Office NotesLaboratory Test ResultsOperative NotesImages and Imaging ReportsConsultation Reports
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is noteffective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtainedas condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this au- thorization.*

I authorize the release of the above indicated medical information to Carolina Spine Center
Name*
Signature*

Clear
Date*

MonthDayYear
Date
Carolina Spine Center Records Release (Revised 01/02/2018)
Should be Empty:

Authorization for the Release of Medical Records

I hereby request that my medical records, as indicated below, be released to Carolina Spine Center for the continuation of patient care:

Authorization for the
Release of Medical Records