Medical Information Release Authorization

Medical Information Release Authorization

400 Ashville Ave., Ste. 200 Cary, NC 27518 | 919.233.1680 (PH) | 919.233.1685 (FAX)
Patient's Name*
Patient's Date of Birth*

MonthDayYear
Patient's Phone Number*
.
Patient's Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
At the request of the individual, I First Name* Last Name* , do hereby authorize North Carolina Center for Reproductive Medicine (NCCRM) to release the following:
Progress NotesHospital NotesPathology ReportsLaboratory ReportsSurgical NotesAll RecordsOther
Additional Authorization*

I authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome), or HIV (Human Immunodeficiency Virus) Infection, psychiatric care, and/or psychological assessment, and treatment for alcohol and/or drug abuse.I do not authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome), or HIV (Human Immunodeficiency Virus) Infection, psychiatric care, and/or psychological assessment, and treatment for alcohol and/or drug abuse.
Purpose of Disclosure*

Referral to specialistLegal InvestigationInsuranceDisability determinationWorkers CompensationPersonalOther
I request the information to be release to:*

Myself (Above Named Patient)Medical ProviderMedical FacilityAgencyOther
Information Released To (Name):*
Information Released to (Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email - If Preferred
Fax Number - If Preferred
I hereby authorize desclosure of the health information for the above named apatient. This authorization is valid for 12 month from the signature date. I understand that I may cancel this request with written notification but it will not affect any information released prior to notification of cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by fereal regulatins. I understand that the medical provider to whom this is authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
Signature of Individual or Personal Representative of Person's Estate*

Clear
Date of Signature

MonthDayYear
**PLEASE NOTE: WE CAN NOT ENTERTAIN SAME DAY RECORD REQUESTS AND IT MAIGHT TAKE UP TO 3 WEEKS TO RECEIVE YOUR RECORDS. THERE WILL BE A CHARGE FOR RECORDS IN ACORDANCE WITH THE $0.75/PG (UP TO PG 26) ADDITIONAL $0.50/PG (FROM 26-100) ADDITIONAL $0.25/PG (FROM 101 AND UP) PLUS THE COST OF POSTAGE. THIS FEE COULD COME FROM OUR FACILITY OR A CONTRACTED FACILLITY CALLED HEALTHPORT.**
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