Transfer Medical Records From CCIM

Transfer Medical Records Form

Use this form to have our office send your records to another medical facility/doctor.
Patient Information
Full Name*
Date of Birth*

MonthDayYear
Phone Number*
Current Address*
Email Address
Carolina Center for Integrative Medicine (Sender)
John C. Pittman, MD

4505 Fair Meadow Lane, Suite 111
Raleigh, NC 27607
Phone: 919-571-4391 Fax: 919-571-8968
New Healthcare Provider (Recipient)

Where would you like your CCIM records to be sent?
Healthcare Facility/Hospital*
Address*

State / Province
Phone Number*
Please enter a valid phone number.
Fax Number
Records to Be Transferred*

Complete Medical RecordOther
Additional Instructions or Comments
Patient/Legal Representative Consent:

I have read and understood this authorization for the transfer of medical records and voluntarily consent to its terms.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Transfer Medical Records Form