North Carolina Medical Records Release Form 3
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NC Orthopaedic Clinic
3609 Southwest Durham Dr, Durham, NC 27707
Phone- 919-403-5140, Fax- 919-477-1929
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
______________________________________

(Print patient’s full name)
______________________________________
(Street address)
_______________________________________
(City, state, zip code)
______________________________________
Email address

___________________________
Birth date (Mo/Day/Yr)
____________________________
social security number
______________________________
Phone (Home)

At the request of the individual, I ________________________, do hereby authorize _______________________ to release:
(patient’s name)
(name of facility)
_____PROGRESS NOTES
_______PATHOLOGY REPORTS
________ ALL RECORDS
______OTHER DOCTORS NOTES
______OB/GYN NOTES
______HOSPITAL NOTES

_____ I do

____ I do NOT

_______LABORATORY REPORTS
_______RADIOLOGY REPORTS
_______ECG/EEG/CARDIC CATH

________OTHER_______________________________________
___________