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The "Carolina Spine and Neurosurgery Center - Carolina Spine and" form is a patient authorization document used by the Carolina Spine and Neurosurgery Center. This form authorizes the disclosure of a patient's health information. It specifies the patient's details and the recipient of the information. Additionally, it outlines the types of records to be released and the purpose for the disclosure.
The form can typically be obtained through the Carolina Spine and Neurosurgery Center's website or by contacting the center directly. Physical copies may be available at the center’s office for patients visiting in person.
Completing the form requires careful attention to detail to ensure all required fields are accurately filled.
Review Patient Information Section:
Specify the Recipient:
Detail Records to be Released:
Purpose for Disclosure:
Several critical components make up the form, each ensuring its legal validity and providing clear instructions on how patient information is handled.
Understanding specific terms can help in accurately completing and utilizing the form.
The form adheres to legal protocols for patient confidentiality and health information sharing.
Patients might need to use the form for various common scenarios, allowing third parties to access necessary information for distinct purposes.
State laws might impose additional requirements or exceptions for the use of this form within specific jurisdictions.
There are specific penalties if the form is not used or respected properly.
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UNC Healths spinal neurosurgery team provides state-ofthe-art management and an individualized treatment strategy for patients with diseases of the spine.
Name: LYNNE CHRISTINE FISCUS M.D.. Title: President Phone: 9842154111. Mailing Address, 2000 PERIMETER PARK DR STE 200. MORRISVILLE, NC 27560-8442. United