Piedmont HealthCare PO Box 1845 Statesville NC-2026

1. Click ‘Get Form’ to open the Piedmont HealthCare authorization form in the editor.
2. Begin by entering the patient's name in the designated field at the top of the form. This is essential for identifying whose health information is being authorized for release.
3. Next, fill in the date of birth to ensure accurate identification. This helps avoid any mix-ups with other patients.
4. Provide the street address or P.O. Box, along with home and work phone numbers. This information is crucial for contact purposes.
5. In the section labeled 'SEND MEDICAL RECORDS TO,' enter the name and complete address of the facility or person receiving the records.
6. Select which specific medical records you wish to disclose by checking the appropriate boxes, such as immunization records or lab reports.
7. Indicate the purpose of this authorization by selecting from options like 'Patient Request' or 'Insurance.'
8. Finally, sign and date at the bottom of the form. If applicable, check your legal authority if you are signing on behalf of someone else.

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