Unc Regional Physicians Medical Records Release Form

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Medical Records
Release Form
I do hereby consent and authorize UNC Regional Physicians to release copies of my medical records.
Patient Name
Medical Record Number
Address
| Street Number or RFD
Phone
City, State and Zip Code
Date of Birth
Social Security Number
X XX - XX-
| Last 4 digits only
RECORDS REQUESTED FROM UNC REGIONAL PHYSICIANS
Name of Person or Facility
Practice Address
| Street Number or RFD
Phone
City, State and Zip Code
Email
Fax
RECORDS TO USE OR DISCLOSE TO
Name of Person or Facility
Practice Address
| Street Number or RFD
Phone
City, State and Zip Code
Email
Fax
Please select all the specific documents that apply to your request:
Clinic Notes
Radiology Reports
Nurses Notes
Emergency Room
Progress Notes
Lab Reports
Operative Reports
Doctor Consults
History & Physical
Pathology Reports
EKG, EEG, EMG
Physician Orders
Discharge Summary
Urgent Care
Other
Please place your initials beside the options below to authorize the release of sensitive information pertainting to:
Mental Health
Drugs or Alcohol
Not Applicable: None of these apply
Genetic Testing
HIV/AIDS/other infectious diseases
Please select the purpose of your request:
Continued Patient Care
Attorney/Legal
Insurance
Social Service/Disability
Worker’s Compensation
Personal
Other
Please select how you would like to receive your request:
Mail to address above
E-mail
Verbal
Pick up at Practice
URGENT: Fax to number
listed above

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