Unc Regional Physicians Medical Records Release Form (Page 2 of 2) in pdf

Unc Regional Physicians Medical Records Release Form Page 2

Medical Records Release Form

Patient Name

Medical Record Number

I UNDERSTAND:

I may revoke this Authorization at any time:

• The revocation will not apply to information that has already been released in response to this Authorization.

• I must revoke this Authorization in writing. The procedure for revoking this Authorization is to present my written

revocation to the UNC Regional Physicians.

I may refuse to sign this Authorization:

• My treatment, payment, enrollment in a health plan, or eligibility for benefits cannot be conditioned upon my

authorization of this disclosure.

• A fee may be charged for copying the protected health information. Please see the Practice Manger for information.

I have been informed and understand the information disclosed pursuant to this Authorization may be subject to

re-disclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no

longer be protected under federal medical privacy law.

Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

If I fail to specify an expiration date or event or condition, this authorization will expire automatically in ninety (90) days

from the date of signature.

I have read and understand the information in this Authorization form.

Patient Signature

Date

Printed Name of Patient

Signature of Authorized Representative

Date

Printed Name of Authorized Representative

Please explain Respresentative’s authority to act on behalf of the Patient

Office Use Only

Date Processed

Stamps/Additional Notes

Processed By

Unc Regional Physicians Medical Records Release Form Page 2