North Carolina Medical Records Release Form 2
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Metro Internal Medicine P.A.
Facsimile Transmittal Sheet
Dr Kenneth A. Holt, MD
3320 Executive Dr
Bldg E, Suite 222
Raleigh, NC 27609
Tel: 919.877.1100 Fax: 919.877.8118

AUTHORIZATION TO RELEASE MEDICAL RECORDS AND PATIENT INFORMATION
All sections must be completed.
Patient’s Name: _____________________________________________

Birthdate: ________________________

Street Address: _____________________________________________

Social Security #: __________________

City, State, Zip: _____________________________________________

Phone #: (home) ___________________

Maiden/Other Names: _________________________________________

(work) ___________________

I authorize Metro Internal Medicine (circle all that apply) to release / receive (circle one) information in my patient
records as directed below:
1. Name and address of person or organization to / from (circle one) whom disclosure is to be made:
Name: ______________________________________________________ Phone #: ____________________