Piedmont Obstetrics and Gynecology
C.F. McDonell MD, J. Robert Goins MD, Anita C. Montes MD, Ryan N. Richardson MD
Cheryl Arnold OGNP, Nancy Sciara OGNP
FORM C
AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
Make sure all blanks are filled in. Failure to do so may prevent or delay processing.
Patient Information: Name_________________________________________________________
Address_______________________________________________________
____________________________________________________________
SSN_______-_______-_______
Date of Birth _______-________-________
Provider (who is releasing the information):
Name_________________________________________________________
_____________________________________________________________
Information requested by Piedmont Obstetrics and Gynecology P.A.
210 13th Avenue Place Northwest
Hickory, NC 28601
Phone (828) 322-3017 Fax (828) 322-1087
Information Requested:
______ All medical records for the last 5 year
______ Other______________________________________
Signature__________________________________________ Date ___________________________
Relationship to the patient if not signed by the patient __________________________________________
* This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations prohibit you from making any further disclosure of it without specific written consent of the person to whom it pertains, or as otherwise permitted by regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. It is our policy to release only medical information documented/dictated by our health care providers.
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