Jeffers, Mann and Artman - Record Release Request Forms

Jeffers, Mann and Artman
Pediatric and Adolescent Medicine, P.A.

Raleigh
2406 Blue Ridge Rd.
Suite 100
Ralegh, NC 27607
Tel: 919-786-5001
Fax: 919-786-5051

Clayton
555 Medical Park Place
Suite 208
Clayton, NC 27520
Tel: 919-359-3500
Fax: 919-359-3501

Cary
300 Asheville Ave.
Suite 260
Cary, NC 27511
Tel: 919-852-0177
Fax: 919-852-0175

Wake Forest
110 Capcom Avenue
Suite 202
Wake Forest, NC 27587
Tel: 919-453-5363
Fax: 919-453-5366

Authorization to Use/Release Form

1. Please click the link below to download the form.

2. If you are given the option of opening the file or saving it to a disk, choose "open the file from its current location."

3. When the form opens click on the correct line, type in the required information.

4. If transferring, be sure to send the form to the practice you are transferring from.

You may fax this form to your doctor's office.

Authorization to Use/Release Form

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