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Get NC UNC Health Care HD 555 2015-2024

DICAL INFORMATION (919) 966-3280, Fax (919) 966-4990 (919) 966-2336, Fax (919) 966-6295 Email: relmedinfo@unch.unc.edu I authorize: Other facility: UNC Health Care System OR To use or disclose to: Name of Person or Facility: Address Phone: City State Fax: Zip Email: The protected health information of: Patient Name: Address Date of Birth: City SS# (last 4): State Phone: Zip UNC Medical Record # Dates of Service: __________________________ Put a CHECKMARK next to the specific d.

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