• Authorization for Release of Medical Records

  • Release From:

    MEDIC -Mecklenburg EMS Agency, 4425 Wilkinson Blvd, Charlotte, NC 28208

  • Dates of Service Requested (MM/DD/YY):

    If exact dates are unknown, approximate dates are acceptable.
  • From:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • To:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • This authorization will expire once the requested health information (as indicated below), for the date(s) listed above, has been released to the recipient named in this document and the stated purpose of the release has been fulfilled.

  • Information to Be Released:

  • This authorization is valid only for the items selected below. A new request is required for any additional information.*

  • Release To (Law Office or Authorized Recipient):

  • Format: (000) 000-0000.
  • Delivery Method:

  • Revocation of Authorization:

    To revoke this authorization, notify MEDIC Records by mail at the address above or via email at Records@medic911.com. Revocation will not apply to information that has already been released under this authorization.

  • Patient Information:

  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Authorization for Release of Medical Records

  • Documentation of authority may be required.

  • Authorized Representative (Non-Patient Requestor):
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Law Office Attestation (Required for Attorney Requests):

  • Release of records will not be processed until appropriate legal documentation such as a Court Order, written authorization, Healthcare Power of Attorney, or other required legal authority has been provided or until this attestation is completed by the receiving law office.
  • By signing below, the law office affirms that it has verified the identity of the patient requesting their own records or confirmed the legal authority of the requester, including parent of a minor child, legal guardian, executor or administrator of the patient's estate, Healthcare Power of Attorney, or Attorney-in-Fact.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • July 2026
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  • Should be Empty: