Epilepsy Institute of North Carolina

The Brain is ... Where You Live

COMPREHENSIVE EPILEPSY PROGRAM PATIENT CARE • EDUCATION • RESEARCH BEHAVIORAL HEALTH CENTER THE BRAIN IS WHERE YOU LIVE

Authorization To Release

Epilepsy Institute of North Carolina
1311 Westbrook Plaza Drive, Suite 100
Winston Salem, NC 27103
Telephone: (336) 659-8202
FAX: (336) 659-8206

Patient Name: D.O.B.: *

I AUTHORIZE THE RELEASE OF THE REQUESTED INFORMATION BELOW:

LABS PROGRESS / NURSE NOTES

TESTING PSYCHOLOGY NOTES

OTHER:

INFORMATION TO BE RELEASED TO OR FROM (PLEASE CIRCLE)
THE EPILEPSY INSTITUTE

NAME(S) OF PERSON(S) TO RELEASE OR RECEIVE INFORMATION:

*

PHONE NUMBER:
*

EMAIL:
*

NAME(S) OF PERSON(S) TO RELEASE OR RECEIVE INFORMATION:

PHONE NUMBER:

I UNDERSTAND THAT MY TREATMENT WILL NOT BE CONDITIONED ON
SIGNING THIS AUTHORIZATION AND THAT I HAVE THE RIGHT TO REFUSE
TO SIGN THIS AUTHORIZATION. I UNDERSTAND THAT INFORMATION
DISCLOSED AS A RESULT OF THIS AUTHORIZATION MAY BE SUBJECT
TO RE-DISCLOSURE BY THE RECIPIENT AND MAY NO LONGER BE
PROTECTED BY FEDERAL OR STATE LAW.

I UNDERSTAND THAT PSYCHOLOGICAL AND NEUROSYCHOLOGICAL TEST
ORDERED BY A REFERRING PROVIDER WILL BE SENT TO THAT PROVIDER.
A REQUEST FOR A COPY OF THAT REPORT MUST BE TO THE REFERRING
PROVIDER AND COME FROM THE REFERRING PROVIDER TO THE PATIENT,
PARENT OR GUARDIAN.

I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS
AUTHORIZATION BY SENDING A WRITTEN NOTIFICATION. I UNDERSTAND
THAT I HAVE THE RIGHT TO INSPECT OR COPY THE PROTECTED HEALTH
INFORMATION AS DESCRIBED IN THIS DOCUMENT. I ALSO
UNDERSTAND THAT THE EPILEPSY INSTITUTE OF NORTH
CAROLINA MAY DENY THE REQUEST.

SIGNATURE: SelfParentGuardian
TODAY'S DATE:
* *

(Patient , Parent, Responsible Party or Personal Representative)

BY SUBMITTING THIS FORM, YOU ARE GIVING CONSENT FOR RELEASE OF ABOVE
MARKED INFORMATION. YOU MAY STILL BE REQUIRED TO 'SIGN' THIS FORM AT OUR
OFFICE FOR OUR RECORDS

Security Code:

Epilepsy Institute of North Carolina