Cedar Ridge Family MedicineHealth Information Management
2480 Summit Parkway, Suite 120, Asheville, NC 28801
Records Office · (828) 555-0148 · Fax (828) 555-0149 · [email protected]
AUTH-2026-04417 Form HIM-3 (Rev. 2026)
Date issued April 9, 2026

Authorization for Release of Protected Health Information

45 CFR §164.508
1
Patient InformationThe individual whose health records are being released
Patient full name
Marcus T. Webb
Date of birth
07 / 14 / 1971
Medical record no.
MRN 0093-44182
Address on file
118 Laurel Bend Rd, Black Mountain, NC 28711
Phone
(828) 555-0207
2
Release DirectionWho is authorized to release these records, and who may receive them
I authorize this provider to RELEASE
Provider / facility
Cedar Ridge Family Medicine
Address
2480 Summit Parkway, Suite 120, Asheville, NC 28801
Phone / fax
(828) 555-0148 / fax (828) 555-0149
to DISCLOSE my records to
Recipient / facility
Dr. Lena Okafor — Blue Ridge Cardiology
Address
900 Biltmore Ave, Suite 410, Asheville, NC 28801
Phone / fax
(828) 555-0312 / fax (828) 555-0313
3
Records to be ReleasedCheck each category authorized for disclosure. Cardiology-relevant records are highlighted.
Laboratory resultsCardiacLipid panels, troponin, BNP, metabolic panels
Imaging & diagnosticsCardiacEKG, echocardiogram, stress test, chest imaging
Office visit & progress notesEncounter notes, assessments, plans of care
History & physicalProblem list, surgical and family history
Medication listCurrent and discontinued prescriptions
Immunization recordVaccination history and dates
Other (specify):Referral letter and consult summary
Date range of records Apr 2024throughApr 2026 or all available records
4
Purpose & Delivery
Purpose of disclosure
Continuing care / referral Second opinion Personal use Other
Specific reason
Cardiology referral and evaluation
Deliver records by
Secure electronic / portal Fax Mail Picked up in person
Deliver to (if different)
Blue Ridge Cardiology secure provider portal
5
Expiration
This authorization expires 90 days from the date signed (by July 8, 2026), or on the earlier date or event I write here: . If no date is given, it expires one year from signing.
6
Your Rights & Consent

Please read carefully before signing

  1. You may revoke this authorization at any time by writing to the Records Office above. Revoking it stops future disclosures but does not undo any release already made in reliance on it.
  2. Your care is not conditioned on signing. Cedar Ridge Family Medicine may not refuse treatment, payment, or eligibility for benefits because you decline to sign — except where the records are needed solely to create them for a third party.
  3. Re-disclosure caution. Once your records are released to the recipient named above, federal privacy law (HIPAA) may no longer protect them, and the recipient could share them further.
  4. A copy is as valid as the original, and you are entitled to a copy of this signed authorization.
I have read and understand this authorization. I am signing it freely and voluntarily, and I authorize the release of the records I have marked above for the purpose I have stated.
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Signature
Marcus T. Webb
Signature of patient
April 9, 2026
Date
Marcus Thomas Webb
Printed name
07 / 14 / 1971
Patient date of birth
Complete the line below only if you are signing on behalf of the patient as a personal representative (parent, guardian, or holder of a health-care power of attorney).
Signature of personal representative
Relationship / authority to act
Date
Cedar Ridge Family Medicine · Health Information Management Authorization to Disclose PHI · Form HIM-3 · Page 1 of 1