Carolina Spine & Neurosurgery Center 2025

1. Click ‘Get Form’ to open the Carolina Spine & Neurosurgery Center document in the editor.
2. Begin by filling in your Patient Name and Patient Address. Ensure that all bolded areas are completed to avoid any delays.
3. Enter your Date of Birth, Home Phone Number, Social Security Number, and Expiration Date in the designated fields.
4. Specify where the information will be sent by providing the Name of Person or Facility, their Address, and Phone Number. Choose between options like MAIL or FAX.
5. Indicate what information you wish to release by checking the appropriate boxes for records such as OFFICE NOTES ONLY or LABORATORY NOTES ONLY.
6. Complete the Purpose of Disclosure section by selecting from options like CONTINUED PATIENT CARE or PERSONAL USE.
7. Finally, sign and date the form at the bottom, ensuring you include your relationship to the patient if applicable.

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