MEDICAL RELEASE IN

Authorization for Release of Information

Kinston Community Health Center
Patient Name
DOB
Address

Address

Street Address Line 2

CityState

Zip Code
Phone No.
Social Security No.
I hereby authorize:
Name
Phone No.
Fax Number
To release my medical record as indicated below to:
Attention: Medical Records

Kinston Community Health Center

324 North Quenn Street

Kinston, NC 28501

Telephone: 252-522-9800 Fax Number: 252-523-9790
Information to be released:
History of Physical Exam

MonthDayYear
Date
Progress Notes

MonthDayYear
Date
Lab Reports

MonthDayYear
Date
X-ray Reports

MonthDayYear
Date
MonthDayYear
Date
Entire Medical Record

MonthDayYear
Date
Purpose of Disclosure:

Changing PhysicianInsuranceConsultation/Second OpinionLegalContinuity of CareMovingOther
I specifically authorize the Release of Information relating to:

Substance Abuse (including alcohol/drug)Mental Health (including psychotherapy notes)HIV related information (AIDS related testing)
Signature of Patient or Legal Guardian

Clear
Date

MonthDayYear
Date
1. I understand that this information will expire one year for the date I have signed this form, unless otherwise specified.

2. I understand that I may revoke this authorization at any time by notifying the providing organization, in writing, and it will be effective on the date notified except to the extent action has already been taken upon it.

3. I understand the information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy regulations.

4. I understand that my health care and payment for my health care will not be affected if I do not sign this form.
Signature of Patient or Legal Guardian

Clear
Date

MonthDayYear
Date
Signature of Witness

Clear
Date

MonthDayYear
Date
Should be Empty:

Information to be released: