Authorization to Release Records

Patient Request to Review or for Copies of Records

Please complete the information below to authorize the release or copy of your medical records.

Patient's Full Name: * 🛈

Patient's Date of Birth: * +

Patient's Phone #:

Which TFD Office Is Your Primary Location? *

How Would You Like to Receive the Records?

In Person Pick-Up or Send Via eMail? *

In-Person Pick-Up

eMail

Pick-Up by Patient or Other Authorized Representative? *

Patient

Authorized Rep

*A photo ID will be required when the records are picked up and it must match the "authorized" name provided on this form

Name of Authorized Representative:

Authorized Representative Phone: * 🛈

Email Address Where You'd Like Us to Send the Records:

Records Requested To Be Released (mark all that apply): *

Xrays

Completed Treatment

Outstanding Treatment

Other

"Other" Description: *

Patient Information

I understand that I have the right to revoke this authorization at any time by sending a written notification to the address above. I understand that a revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward.

I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

This authorization shall be in force and effect until the requested items have been delivered or the information has been reviewed by the patient.

Signature of Patient or Personal Representative *

clear

Today's Date: * +

Apex - Green Level	Apex - Kelly Rd	Brier Creek
Cary Park	Fuquay-Varina	Heritage Branch
Morrisville	Pittsboro	Rolesville
WF - Rogers Rd