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Mecklenburg Neurological Associates
Authorization to Use or disclose protected health information.

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Patient Name
  DOB SSN
Address
  City   St   Zip
Please check one of the boxes below for release of medical information:
Release information only to me: Yes No
 
All Records Lab results
X-ray reports Radiology scans
Physician notes Other
Release information to spouse or other person listed: Yes No
Spouse’s Name/other:
Release records to other: Yes No
Name:
Phone #
Address Street:
  City   St   Zip
If you need to contact me you may leave messages on my answering machine? 0Yes 0No
Phone #
This Does/Does Not identify me by name?
Date:
Acknowledgement of Receipt of Notice of Privacy Practices

MNA reserves the right to modify the privacy practices outlined in the notice. I understand that the information in my record may include information relating to sexually transmitted diseases, HIV/AIDS, or any other medical condition. It may also include information about behavioral or mental health services or treatment for alcohol and drug use. I also understand my information will be released and shared among healthcare professionals involved in my care and to my insurance plan for processing of claims. I have received a copy of the Notice of Privacy Practices for MNA. I understand in order to revoke this authorization I must do so in writing.
Name of Patient
Patient’s Representative
Relationship to Patient
Expiration of Release