Transfer of Medical Records to CCIM

Transfer Medical Records to Carolina Center

This form is provided as a courtesy. You may use it to request medical records to be sent to our office.
Medical records hold a wealth of information, including your medical history and specific treatment details. Obtaining this information from your primary care/specialty physicians allows the Carolina Center for Integrative Medicine to have a fuller understanding of your medical history.

This form has a print button at the bottom. You may complete it electronically or by hand (after printing). Distribute the printed copies to your medical providers, allowing them to transfer your information to us.

Do not have copies of x-rays sent. We only need the reports/records.

Please make copies of any records you may have prior to your initial office visit. Records will not be copied or returned to you.
Patient Information
Full Name
Date of Birth
Phone Number
Email Address
Patient's Address
Current Healthcare Provider (Sender)

Your primary care/specialty physicians
Healthcare Facility Name and Address
Carolina Center for Integrative Medicine (Recipient)
John C. Pittman, M.D.
4505 Fair Meadow Lane, Ste 111
Raleigh, NC 27607
Phone 919.571.4391 Fax 919.571.8968
Records to be Transferred

Complete Medical RecordsOther (please be specific)
List specific records to transfer
Patient/Legal Representative Consent:

I request that copies of my medical records along with any other pertinent labs or radiology reports related to my condition be sent to the Carolina Center for Integrative Medicine at the above address.

I have read and understand this authorization for the transfer of medical records and voluntarily consent to its terms.
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Transfer Medical Records to Carolina Center

Patient Information

Current Healthcare Provider (Sender)

Carolina Center for Integrative Medicine (Recipient)