Form

Patient Transition and Medical Records Request

Carolina Cognitive and Behavioral Health
Jaime (Havah) E. Michaels, DNP, PMHNP-BC

NC Neuropsychiatry is scheduled to close permanently on November 30, 2026. Patients who wish to continue care with Havah E. Michaels, DNP, PMHNP-BC, may request to establish care with Carolina Cognitive and Behavioral Health.

Completing this form records your preference and, where applicable, authorizes the release of your medical records. You may choose any healthcare provider, and your decision will not prevent you from obtaining your records.

I've made this transition easy for you. Simply completing this short, secure form authorizes the transfer of your records to my practice at Carolina Cognitive and Behavioral Health
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Patient Election
MEDICAL RECORDS REQUEST & HIPAA AUTHORIZATIONOnly for patients electing to continue care.
Electronic Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name of Person Signing
If Signed by Representative : Relationship / Authority
- e.g., Parent, Legal Guardian, Healthcare POA
A) INFORMATION TO BE DISCLOSED

Copies of relevant psychiatric medical records, including but not limited to intake assessments, psychiatric evaluations, treatment plans, progress notes, medication history, laboratory results relevant to psychiatric care, and correspondence, for the period of care at NC Neuropsychiatry.

Note: Sensitive information protected under 42 CFR Part 2, if applicable, will only be included with specific authorization as required by law.

B) PURPOSE OF DISCLOSURE

To facilitate evaluation for continued care, treatment planning, and continuity of care with the receiving provider.

C) RECIPIENT / RECEIVING PROVIDER

Carolina Cognitive and Behavioral Health

Attn: Havah E. Michaels, DNP, PMHNP-BC

Website:https://www.carolinacbh.com | Tel: (984) 399-9688 | Email:admin@carolinacbh.com

D) EXPIRATION

This authorization expires on: 12 months from date signed OR upon completion of records transfer and closure of NC Neuropsychiatry, whichever occurs first, unless revoked earlier.

E) VOLUNTARY & CONDITIONAL STATEMENTS

    •    I understand this authorization is voluntary and I may refuse to sign without affecting my ability to obtain treatment, payment, or eligibility for benefits, except as permitted by law.

    •    I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

    •    I understand I have the right to revoke this authorization at any time in writing to NC Neuropsychiatry, except to the extent action has already been taken in reliance on it. Revocation instructions: Send written revocation to NC Neuropsychiatry Practice Administration [INSERT ADDRESS/EMAIL FOR REVOCATION].

F) COPY

I understand I am entitled to receive a copy of this signed authorization upon request.
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Patient Transition and Medical Records Request