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.
Format: (000) 000-0000.
Social Security No.
I hereby authorize Kinston Community Health Center to release information from my medical record as indicated to:
Name
Phone No.
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState

Zip Code
Information to be released:
History of Physical Exam

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Progress Notes

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Lab Reports

MonthDayYear
2 digit month, 2 digit day, 4 digit year
X-ray Reports

MonthDayYear
2 digit month, 2 digit day, 4 digit year
MonthDayYear
2 digit month, 2 digit day, 4 digit year
Entire Medical Record

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Purpose of Disclosure:

Other
I specifically authorize the Release of Information relating to:
Signature of Patient or Legal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Witness
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Information to be released: