Avance Primary Care | Avance Primary Care - Authorization for Release of Medical Records Form

Authorization for Release of Medical Records Form

Office Location

Avance Care - Neurology

Please do not use any special characters on this form,including quotes or apostophe

Patient Information

*Patient First Name

*Patient Last Name

*Date of Birth

*Sex Assigned at Birth

Other Information

Account No

Guardian First Name

Guardian Last Name

Relationship to Patient

*Release To/From
- Request to transfer records FROM the office listed on the next page to Alo/Avance Care (4705 UNIVERSITY DRIVE/BLDG. 700, Durham, NC 27707, Fax (919) 237-1625)
- Request to transfer records FROM Avance Care, P.A. to the office listed on the next page
- Request to transfer records TO myself (patient or legal guardian) for personal use
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If you are unable to validate your information, please contact our Medical Records Department at 919-237-1337 Option 6.