For your convenience print the
medical release form and fax
cover sheet below.
MEDICAL RECORDS RELEASE FORM
FAX COVER SHEET
A fee will be charged for all
medical record requests of .25¢ per page.
Copy Fee
***PLEASE READ SPECIAL NOTICE***
January 26, 2012
Dear Patients,
It is with mixed emotions that I am announcing I will be taking a medical leave of absence and closing my medical practice, effective immediately. It has been a pleasure providing for your health care needs over the years, and it is not easy for me to give this up.
As of March 1, 2012 Cary Women's Center will close. I recommend looking for a new physician as soon as possible. I will provide emergency services for the next 30 days.
Your medical records are confidential, and a copy can be transferred to another doctor, to you or to another person you designate only through written permission. If you have another physician you would like your records transferred to, we will need you to sign a medical release authorization form as soon as possible so we may transfer your records to your new doctor. Until then, your records will remain on file.
I have greatly valued our relationship and thank you for your loyalty over the years. Best wishes for your future health.
Sincerely,
Christy L. Clayton, MD
January 26, 2012
Dear Patients,
It is with mixed emotions that I am announcing I will be taking a medical leave of absence and closing my medical practice, effective immediately. It has been a pleasure providing for your health care needs over the years, and it is not easy for me to give this up.
As of March 1, 2012 Cary Women's Center will close. I recommend looking for a new physician as soon as possible. I will provide emergency services for the next 30 days.
Your medical records are confidential, and a copy can be transferred to another doctor, to you or to another person you designate only through written permission. If you have another physician you would like your records transferred to, we will need you to sign a medical release authorization form as soon as possible so we may transfer your records to your new doctor. Until then, your records will remain on file.
I have greatly valued our relationship and thank you for your loyalty over the years. Best wishes for your future health.
Sincerely,
Christy L. Clayton, MD
Patient's with billing questions, please contact our billing service MBM at 423-629-9783.