I hereby grant CAROLINA HOUSE
Location: 176 Lassiter Homestead, Road, Durham, NC 27713
Phone: 919-864-1004 ;
FAX: 877-275-7813
By submitting and digitally signing this form, I hereby authorize CAROLINA HOUSE or agent, to disclose information contained in the medical and financial record of the patient identified above, which includes information that may be stored in a paper and/or other electronic format.
However, such notes may contain information on general medical care; alcohol and drug abuse treatment; psychological and socialwork counseling; human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS), or AIDS related complex. Including communicable diseases or infections, sexually transmitted diseases, venereal diseases, tuberculosis and hepatitis; demographic information; and treatment received at other health care facilities.
Disclosure shall be limited to the following specific information contained in my records and/or obtained during the course of my diagnosis and treatment.