Patient's Name

Birth Date

Address

Home Phone

City/State/Zip Code

Other Phone

From

Facility Name

Facility Address

I hereby authorize and request you to release to

from

Raleigh Medical Group Gastroenterology
Wake Endoscopy Center, LLC
2601 Lake Dr., Ste 201
Raleigh, NC 27607
Phone: (919) 783-4888 Fax: (919) 783-4887

Release (Check all that apply):

All Records

Specific Dates

Diagnostic Records

Are you permanently transferring your care to another GI practice/provider? Yes No

Reason for transfer/request

I understand that the information in my medical record may include information relating to sexually transmitted diseases, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services and/or treatment for alcohol and drug abuse.

Signature

Date

Witness

Date

This authorization will expire 180 days from date executed unless otherwise specified.

All requests will be processed within 10 business days of the date of the request. We will make every effort to accommodate special requests but this is not always possible. There may be a fee associated with processing any request for medical records. Please contact our medical records department for further information. We now use a third party (DataFile) for your chart releases.

RALEIGH MEDICAL GROUP GASTROENTEROLOGY

WAKE ENDOSCOPY CENTER. LLC