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Authorization and Release of Medical Records

Authorization and Release of Medical Records

Release Information: * I Authorize and Request records to be sent to Mountain Kidney & Hypertension Associates from the Medical Office listed below:
(Enter the information for the Medical Office that needs to send records to us)

* Medical Office:

* Phone:

Fax:

To release medical information pertaining to:

* Patient Name:

* Patient Phone:

* Date of Birth:

* Please choose one of the following:

Entire Medical Record

Request for Medical Records from -

From (Date):

To (Date):

Lab/Radiology

Forward Labs to (Enter Doctor Name below):

Other (describe below):

* This information is to be released to (please check one):

Joseph R. Aiello, MD

John A. Manley, MD

Sarita Cross, MD

W. Blake Pruitt, MD

Brian E. Jones, MD

Nam D. Vo, MD

William T. Durham, MD

Matthew J. Volk, MD

Brian K. England, MD

T. Scott Robbins, MD

-

S. Bryson Fleming, MD

Mary Parker, FNP

James E. Yates, MD

Marlene Winters, ANP

Aija Pertee, FNP

Paul Justice, ANP

Laurie Lowdermilk, ANP

I consent and authorize the above medical office to release copies of my personal medical record(s) by fax or mail, including current and previous medical records. Please release copies of all requested information.

Signature of Patient/Legal Guardian (Type Name Below):

Date:

Mountain Kidney & Hypertension Associates, P.A.

10 McDowell Street
Asheville, NC 28801
Phone: (828) 258-8545
Fax: (844) 378-7512
Billing Inquiries: (828) 258-5540

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Rutherfordton, Spruce Pine and Sylva

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