Transcription of Please send completed authorization form to
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Example: dental hygienist
Please send completed authorization form to
Chart Location: authorization Please send completed authorization form to: 601 North Elm Street High Point, NC 27261 Office: 336-878-6020 Fax: 336-878-6100 I authorize: To use or disclose to: The protected health information of: Patient Name: Date of Birth: SS# (last 4): Address City State Zip Phone: Medical Record # Dates of Service: _____ Put a CHECKMARK next to the specific documents that apply to your request: Clinic notes (outpatient) Operative / Procedure notes Progress Notes (inpatient) Emergency Dept.
Rev.7/12/17 Chart Location: Authorization Put a CHECKMARK next to how you would like to receive your request: *Access via MyUNC Chart will only be available for 30 days; although you may print and/or save a copy for your personal use.
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