901 Denim Drive, Erwin, NC 28339
      Phone: 910-897-5521 * Fax: 910-897-2003
      Md A Karim, MD * Sarah Stall, PA-C 
      Orlinda Martinez, PA-C  * Ashley Irons, FNP-C




MEDICAL RECORDS REQUEST FORM


Patient details: This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability  Act of 1996 (HIPAA) privacy standards:
        Patient Name: _______________________________________
        Date of Birth: _______________________________________


Authorization
The above named patient authorizes ____________________________________ to release:
* All of my medical related information
* My medical related information from _____________________ to ______________________
* Other: __________________________________________________________________________________


Requesting Party:
        Name: ________________________________________________
        Relationship to Patient: _____________________________
        Contact Number: ____________________________________


Purpose of Disclosure:
* Referral to Specialist        
* Legal Investigation
* Insurance
* Disability Determination
* Personal
* Others (please specify): 


Administrative Fee Paid (for printed records): ___________________________________________




_____________________________________________                        ____________________________________________
Signature of Patient or Representative                                                Date


_____________________________________________                        ____________________________________________
Print Name                                                  Witness Signature and Initials


Although allowed under HIPPA, North Carolina law does not permit release of PHI outside of the Hospital unless required by law, pursuant to a court order or patient authorization, or for treatment, payment, or health care operations purposes as defined and limited by HIPAA. There is no exception for family members except for residents of a nursing home. The North Carolina physician-patient privilege statute, N.C.G.S. § 8-53, and HIPAA allow verbal authorization or consent for release, respectively, of information to family members. However, the better practice is to document the patient’s consent in order to have clear evidence of the patient’s intent. The package does not include a consent or authorization to release PHI to other providers or to insurance companies or others since most providers already have such forms. The contents of this form can be combined with such existing consent forms.


I hereby authorize disclosure of the health information for the above patient. The authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification of cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or class or facility receiving it and would no longer be protected by federal regulations.