MEDICAL RECORDS RELEASE

MEDICAL RECORDS RELEASE

NCCRM 400 Ashville Ave. Ste. 200A, Cary, NC 27518 | 1517 N Church St., Greensboro, NC 27405
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Patient Medical Records Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Contact Number*
.
Patient Email*
Name of Facility and Department Where the Ligation was Performed*
FAX Number of Facility*
Please enter a valid FAX number. Submitting a telephone number will delay request and approval process.
Year of Tubal Ligation Procedure (or unknow)*
If unknown, please state "unknown"
I, the undersigned, authorize the medical provider to release information from my medical records, including treatment for psychiatric conditions, substance use, and HIV/AIDS. Please release the operative note and pathology report from my tubal ligation and send them to Dr. Sameh Toma at 919-336-5089 (fax) or NCCRM Tubal Reversal, 400 Ashville Ave. Ste. 200, Cary, NC 27518 (mail).

This authorization must be signed and dated. It may be revoked at any time in writing, except for actions taken before revocation. It will expire six months from the date below. I confirm I have read and understand these statements and that signing this authorization does not affect my treatment, payment, or eligibility for benefits. I authorize the disclosure of my medical records as stated.
Signature*

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Today's Date*

MonthDayYear
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