MEDICAL RELEASE OUT

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 Kinston Community Health Center to release information from my medical record as indicated to:
Name
Phone No.
Address

Address

Street Address Line 2

CityState

Zip Code
Information to be released:
History of Physical Exam

MonthDayYear
Progress Notes

MonthDayYear
Lab Reports

MonthDayYear
X-ray Reports

MonthDayYear
MonthDayYear
Entire Medical Record

MonthDayYear
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: