Patient Name
Date of Birth
Street Address
City
State
Zip
Cell Phone #
Home #
I authorize Catawba County Public Health to send my records to the below listed facility
(Name of medical, agency, person, company)
(Address or email address
(Office or contact phone number)
(Fax)
I want these parts of my records released: (Check all that apply from each)
Office/Clinical
(Check all that apply).
Immunization Records
Program records to be released
(Check all that apply)
Immunizations
I want these records sent by:
I want these records sent by
Mail to the street address listed
Mail to the office, facility, person or company listed
Fax to the office, facility, person or company listed
Prepare to be picked up by myself or the person with legal authority
Email to the email address listed above
As an alternative you may schedule an appointment with our office to see your records in person to review instead of obtaining a copy. Please note it may take up to 30 days to schedule the appointment or provide copies
Printed Name of Patient or Legal Representative:
Signature of Patient or Legal Representative:
Date
Fill out below if you are requesting and are not the Identified patient(s)
I certify I have a Power of Attorney for the above Identified Patient and have attached the necessary documents to verify such. (NOTE: These documents must specifically state the Power of Attorney covers medical matters.)
I certify I have a Power of Attorney for the above Identified Patient and have attached the necessary documents to verify such. (NOTE: These documents must specifically state the Power of Attorney covers medical matters.)
I certify I am the legal guardian of the above Identified Patient and have attached the necessary documents to verify such.
I certify I am the legal guardian of the above Identified Patient and have attached the necessary documents to verify such.
I certify I am the Administrator/Administratrix of the estate of the above identified deceased Patient and have attached the necessary documents to verify such.
I certify I am the Administrator/Administratrix of the estate of the above identified deceased Patient and have attached the necessary documents to verify such.
I certify I am the Next of Kin for the above identified deceased patient. I further state I am their spouse (or if the patient was not married at the time of death, the parent) and to the best of my knowledge the deceased patient did not have a will and no Executor of the Estate has been appointed by the court.
I certify I am the Next of Kin for the above identified deceased patient. I further state I am their spouse (or if the patient was not married at the time of death, the parent) and to the best of my knowledge the deceased patient did not have a will and no Executor of the Estate has been appointed by the court.
Submit