Authorized Representative - Authorization for Release of Medical Records and Attestation

Authorization for Release of Medical Records
Purpose of Release:

Other
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:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
To:

MonthDayYear
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.

Other
Release To:
Name of Law Office:
Street Address:
City, State, Zip:
Telephone:
Format: (000) 000-0000.
Email Address:
Fax:
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:
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last 4 digits of SSN (optional):
Street Address:
City, State, Zip:
Telephone:
Format: (000) 000-0000.
Email Address:

For AUTHORIZED REPRESENTATIVES requesting release of records to representing attorney:
Authorized Representative (Non-Patient Requestor):

Other
Name of Requestor:
Signature of Requestor:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Law Office Attestation:
For any request that is not signed by the patient, records will not be released until appropriate legal documentation such as a Court Order, written authorization, Healthcare Power of Attorney, or other valid legal authority is provided, or until this attestation is completed by the requesting law office.

By signing below, the law office affirms that it has verified the requester’s legal authority, which may include a parent of a minor child, spouse, next of kin, legal guardian, executor or administrator of the patient’s estate, Healthcare Power of Attorney, or Attorney in Fact.
Printed Name:
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: