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  • Authorization for Release of Information

    Kinston Community Health Center

  • Format: (000) 000-0000.

  • I hereby authorize:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 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
     - -
    2 digit month, 2 digit day, 4 digit year
  • Progress Notes
     - -
    2 digit month, 2 digit day, 4 digit year
  • Lab Reports
     - -
    2 digit month, 2 digit day, 4 digit year
  • X-ray Reports
     - -
    2 digit month, 2 digit day, 4 digit year
  •  - -
    2 digit month, 2 digit day, 4 digit year
  • Entire Medical Record
     - -
    2 digit month, 2 digit day, 4 digit year
  • Purpose of Disclosure:
  • I specifically authorize the Release of Information relating to:
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • 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.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: