Engelhard Medical Center
PO BOX 277
Engelhard, NC 27824-0277
I HEREBY AUTHORIZE:
TO RELEASE MY MEDICAL RECORDS TO:
Duration: This authorization shall become effective immediately and shall remain in effect for one year.
Revocation: My written revocation will be effective upon receipt, but will not be effective to the extent the requester or others have acted in reliance upon this authorization.
Redisclosure: I understand that the requester may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law.
Confidentiality Notice: This information is confidential, intended for the use of the addressee listed above. If you are neither the intended recipient nor the employee or agent responsible for delivering this transmission to the intended recipient, you are hereby notified that any disclosure, copying, distribution or the taking of any action in reliance on the contents of this transmission is strictly prohibited. If you have received this transmission in error, please immediately notify us.