Authorization for Release of Information
Released From Mecklenburg EMS Agency 4425 Wilkinson Blvd Charlotte, NC 28208 704-943-6000 records@medic911.com
Patient Name
*
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Date of Birth
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Requested Information
*
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Release Information to the Following
Name
*
First Name
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Relationship to Patient
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Phone Number
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*
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
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Address
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Street Address
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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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