Authorization for Release of Information
Released From Mecklenburg EMS Agency 4425 Wilkinson Blvd Charlotte, NC 28208 704-943-6000 records@medic911.com
Patient Name
*
First Name
Last Name
Date of Birth
*
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Date
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Format: (000) 000-0000.
Address
*
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*
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Requested Information
*
Patient Care Report
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Release Information to the Following
Name
*
First Name
Last Name
Relationship to Patient
*
Phone Number
*
Fax Number
Email Address
*
Delivery Method
*
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Unsecured Email
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Release only valid for 1 year with signature
Purpose for Release
*
Continuation of Care
Legal
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Address
*
Street Address
Street Address Line 2
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Postal / Zip Code
Supporting Documents
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Consent
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I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time to records@medic911.com. I also understand that my information may be transmitted unsecured, and that such transmission may carry some risk of unauthorized access.
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