Medical Records Release

I hereby authorize and request Regional Primary Care, Inc. to use and disclose my personal, private Protected Health Information including release of a copy of my medical record or a specified portion of my medical record as indicated below on this form. I understand that the information I am authorizing Regional Primary Care, Inc. to release to the person, class of persons or organization named below may be re-disclosed and no longer protected by federal privacy regulations.

I understand that I may revoke this authorization at any time by in writing and that I may use a form furnished by Regional Primary Care, Inc. to make the written revocation. I also understand that if I revoke this authorization, my revocation will not affect any health information that was released according to the terms of this authorization before the date of my revocation. I also understand that I may not revoke authorized use and/or disclosures obtained in connection with my receipt of insurance coverage.

I understand that this authorization is voluntary, my treatment by Regional Primary Care, Inc. will not be conditioned on the completion of this authorization and I have a right to request and receive a copy of this authorization.

(Please check appropriate box)

I have read and understand this Authorization for Release of Protected health information and I have signed it voluntarily.

*Psychotherapy Notes: This authorization does not include permission to release Psychotherapy Notes. Psychotherapy Notes are defined as notes that document private, joint, group, or family counseling sessions that are separated from the rest of an Individual/s medical record. If Regional Primary Care, Inc. maintains Psychotherapy Notes concerning me, I understand that I may authorize release of Psychotherapy Notes by means of a separate authorization that will be furnished if I require it.

Today's Date: 10/30/2020