Information Release Consent Form In Wake

State:
Multi-State
County:
Wake
Control #:
US-00459
Format:
Word; 
Rich Text
Instant download

Description

This Consent to Release of Financial Information authorizes all banks, financial institutions, businesses, employers, credit reporting agencies and any other businesses to which this person is indebted or have assets located, to provide information concerning his/her finances and assets, without liability, to the person or entity named in this Consent form. This form is applicable in any state.

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FAQ

As Wake County's only provider of trauma services and a regional trauma referral center, our two trauma centers — a Level I Trauma Center at Raleigh Campus and a Level III Trauma Center at Cary Hospital — and the WakeMed Trauma teams are standing ready to provide immediate care for the seriously injured.

Release of information (ROI) allows patients to release information from their medical records to authorized individuals or organizations.

Phone Directory Department namePhone number Main Phone 469.764.8000 Business Office/Billing Questions 214.820.2278 Medical Records 469.764.9110 | Fax: 469.764.9118 Physician Referral 1.844.BSW.DOCS (1.844.279.3627) (1.844.279.3627)2 more rows

For immediate continuity of care requests, you or your health care provider can request that records are sent directly to their office. Use the form above, or your provider's office can fax a written request on business letterhead to 619-543-7128.

Fax Numbers: Cary Hospital: 919-350-2285. North Hospital: 919-350-6892.

WakeMed is a large, off-campus teaching site for the UNC School of Medicine — an affiliation that has been in place for over 40 years. Many physicians in the WakeMed community have graduated from medical education programs at UNC. Around 50 residents rotate at WakeMed — most from UNC with a few from Duke University.

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.

Some common synonyms of disclose are betray, divulge, reveal, and tell. While all these words mean "to make known what has been or should be concealed," disclose may imply a discovering but more often an imparting of information previously kept secret.

What Is a Release of Information? A release of information is a document that gives a consumer the opportunity to decide what material they want released from their medical file, who they want it delivered to, how long the data can be issued, and under what statutes and guidelines it is released.

Personal health record (PHR) Electronic medical record (EMR)

More info

This authorization will remain valid until revoked or upon expiration of one year from the date of this signed release. How to Request Your Medical Records.Please download the release form that best suits your situation. Click on the link below to complete your request for medical records. You will be required to provide a valid email address and a government-issued ID. Signature on this form grants permission to release the decedent to Wake Forest University. Commonly Used Wake Patient Forms: Registration Form, Registration Form, Health History Form, Health History Form, Medication List For Wake Patients. Signature on this form grants permission to release the decedent to Wake Forest University. For your convenience, please find our most commonly used Wake patient forms below. Commonly Used Wake Patient Forms.

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Information Release Consent Form In Wake