RALEIGH MEDICAL GROUP GASTROENTEROLOGY

(A Division of Raleigh Medical Group, P.A.)

WAKE ENDOSCOPY CENTER. LLC

2601 Lake Drive, Suite 201
Raleigh, NC 27607
Telephone (919) 783-4888 Fax (919) 783-4887

Chart No.

Date

I give my permission for the providers of Raleigh Medical Group, P.A. to release ANY information about my medical condition, prescriptions, and financial account to:

Name

Below, I give my permission for the providers of Raleigh Medical Group, P.A. to release prescriptions and samples ONLY to:

Name

The above-mentioned person(s) will be required to provide photo ID when picking up requested items.

Patient Name

Date of Birth

By signing on the line below, I acknowledge that I was provided access to Privacy Practices of Raleigh Medical Group, P.A.

Patient Name

Date of Birth

Patient Signature

For Personal Representation of the patient (if applicable)

Print Name of Personal Representative

Representative’s Relationship

Signature of Personal Representative:

I refuse to acknowledge I was provided access to the Notice of Privacy Practices of Raleigh Medical Group, P.A.