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2020 NC Port City Neurosurgery & Spine Authorization to Disclose Health Information-2026
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- Click ‘Get Form’ to open the document in our platform's editor.
- Begin by entering the patient's full name in the designated field at the top of the form.
- Fill in the date of birth, social security number, and phone number in their respective fields.
- In the authorization section, specify who is authorized to receive the health information by entering their name.
- Select the purpose for disclosure by checking one of the provided options: Specialist Consultation or Transferring my chart and medical care.
- Choose what specific information you wish to disclose: either your entire chart, records for a specific period, or a specific portion of your record.
- Review the expiration details and understand your rights regarding revocation and re-disclosure before signing.
- Sign and date the form where indicated. If applicable, have a legal guardian sign as well.
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