Authorization for Release of Health Information AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION Patient’s Legal Name (print) Date of Birth Preferred Name Facility or Physician Sending Your Records Western North Carolina Community Health Services Name Address Phone Fax Facility, Person, or Company Receiving Your Records Western North Carolina Community Health Services Name Address Phone Fax Treatment Dates (choose only one) Last 3 Years (standard release) All Treatment Dates From To Purpose of Release Continuing Care Personal Use Legal Disability Insurance Other Type of Medical Records Being Requested (choose only one) Standard Release Behavioral Health All Medical Records Other Dental Records Requested Dental Visit Notes Dental Imaging (CD or Email) Format Requested / Delivery Method Fax (health care providers only) Pick up Mail MyChart Communication between sending & receiving parties Email Other Exclude Sensitive Information (optional) Mental Health / Psychiatric Treatment Genetic Testing Alcohol or Substance Abuse Treatment STI / HIV / AIDS Treatment or Testing My authorization will be valid for one (1) calendar year or until I revoke it in writing. Once disclosed, information may be re‑disclosed and may no longer be protected by law. By signing below, I acknowledge that I have read and understand this Authorization. Signature of Patient or Legal Guardian / Representative Date If not signed by patient, print name of Legal Guardian / Representative Relationship to Patient Witness Signature (if applicable) Date Minnie Jones Health Center • Hominy Valley Health Center • McDowell Health Center Centralized Medical Records Department – 257 Biltmore Ave, Asheville, NC 28801 Fax: 828‑285‑9831 • Email: medicalrecords@wncchs.org