Release Of Records To WSPS From Another Provider

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

Maiden or Other Name(s)

I hereby request and authorize:

Wake Spine & Pain Clinic
3801 Wake Forest Rd, Suite 210
Raleigh, NC 27609
Phone: (919) 787-7246
Fax: (919) 787-7247
Email: info@wakespine.com

to receive my health records from the following Person/Organization. The following Person/Organization is hereby authorized to SEND MY HEALTH RECORDS TO Wake Spine and Pain Specialists:

Clinic/Hospital Name(Required)

Clinic/Hospital Address or Fax Number

Delivered by FAX.

For the purpose of Continuity of Care.

Health Information to be Released(Required)

Progress/Clinic notes

Lab Results

Radiology Reports (no disk)

Physical Therapy Notes

Injections/Procedures

Psychotherapy Notes

Other

Please select all that apply.

Information NOT to be Released(Required)

DO NOT release Alcohol/Drug Use or Abuse records

DO NOT release Mental Health records

ALL records may be released

If you allow ALL records to be released, please DO NOT check any of the other boxes.

Dates of Treatment to be Released(Required)

Please release records for a specific time period

Please release records pertaining to a specific injury or illness

Please release the most recent 6 months of records

Please release all records

Authorization/Revocation

This authorization will terminate in one year unless otherwise specified. I may revoke this authorization at any time by notifying the releasing organization in writing. It will be effective on the date notified except to the extent action has already been taken. This authorization is valid for records prior to and after the date signed. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by Federal Privacy standards. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization. In compliance with MN Statute 144.33, I may be required to pay a fee for retrieval and photocopying of records and/or supervising inspection of medical records. I may receive a copy of the signed authorization upon request. A photocopy or fax of this document is valid as the original. Twin Cities Pain Clinic will not release medical records obtained from another health care provider or facility.

Date(Required)

Name

This field is for validation purposes and should be left unchanged.