Medical Record # _________________________
8401 Medical Plaza Drive, Suite 300, Charlotte NC 28262
PHONE: (704) 316 6561 FAX: (704) 384-1974
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
Autorizacion Para Obtener Informacion De Salud
PATIENT INFORMATION: (Información del paciente)
Date of Birth: (Fecha de Nacimiento) _________________
___________________________________________ __________________________________________ __________________
Last Name (Apellido) First Name (Nombre) Middle Initial (Inicial)
___________________________________________ __________________________________________ __________________
Street Address (Calle y Numero) Apt # (Apartamento #)
___________________________________________ __________________________________________ __________________
City (Ciudad) State (Estado) Zip Code(Codigo Postal)
INFORMATION RELEASE FROM: (Informacion Viene De) INFORMATION RELEASED TO: (Informacion publicada A)
___________________________________________ __CHARLOTTE COMMUNITY HEALTH CLINIC_______________
Health Care Provider (Proveedor de Servicios Medico) Health Care Provider (Proveedor de Servicios Medico)
___________________________________________ __8401 Medical Plaza Drive, Suite 300____________________
Street Address (Calle Y Numero) Street Address
___________________________________________ __Charlotte NC 28262__________________
City (Ciudad) State (Estado) Zip Code Codigo Postal City (Ciudad) State (Estado) Zip Code (Codigo Postal)
THIS INFORMATION SHALL INCLUDE THE FOLLOWING: Date(s) of Service of Release ________________________________________
□ Discharge Summary □ Operative Report □ Radiology Report
□ History & Physical □ Pathology Report □ Emergency Report
□ Progress/Office Notes □ Laboratory Report □ Progress Notes
□ Consultation □ ECG/EEG Cardiac Cath □ Entire Record
□ Other (Specify) __________________________________________________________________________
NOTICE: This authorization is for DISCLOSURE OF ALL RECORDS, including clinical findings, diagnosis, treatment, assessment, recommendation, for further care, names of health
care personnel, dates of hospitalization and ambulatory visits, charges and any information that may be related to drug, alcohol, psychiatric conditions and/or sexually
transmitted disease, including HIV/AIDS information. Such records will be disclosed unless specified information to exclude listed below.
EXCLUSIONS: __________________________________________________________________________________________________________________
PURPOSE FOR DISCLOSURE:
□ Continuing Treatment □ Legal Investigation □ Disability Determination □ Personal
□ Other (please specify): _____________________________________________________________________________________________
RESTRICTIONS:
I understand that the recipient of this information may not use or disclose the information unless authorization is obtained from me or unless such use or disclosure is specifically
required or permitted by law. I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 90 days from the date of
signature. I understand that I may cancel this request with written notification but that it will not have any effect on information release prior to notification of cancellation.
SIGNATURE OF PATIENT/LEGAL AUTHORITY
(FIRMA DEL PACIENTE/AUTORIDAD LEGAL): ______________________________________________ Date (Fecha) : _______________
LEGAL AUTHORITY IS:
□ Guardian □ Attorney-In-Fact □Guardian Next of Kin □Other: Specify :_________________________________________
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