Medical Records Release Form
To Request a Medical Records Release Online:
Click HERE to complete the form and submit to Pinehurst Medical Clinic’s Medical Records Department.
*Please allow 5-7 business days for the request to be processed. Additional time may be required for mail delivery.
If you have already submitted an online request and have questions concerning your request, please contact the Medical Records Department via phone at (910) 235-3069.
To Request a Medical Records Release via Mail:
Print, complete and mail the following form: Release of Medical Information
Mail the completed Release of Medical Information Form to:
Pinehurst Medical Clinic
Attn: Medical Records,
205 Page Road,
Pinehurst, NC 28374 OR Fax to: (910)235-3413
(Please note that we use a copying service and charges may apply.)
Telehealth Advance Beneficiary Notice of Non-Coverage (ABN)
Click Here
Please sign and fax the ABN Form to your PMC provider's office. Fax numbers can be found via the provider’s bio or reviewing the location page for your provider.
Patient Forms
Please print, fill it out, and bring any relevant forms with you to your appointment.
Cardiology Forms
Dr. Anderson/Dr. Kent Patient History Form
Dr. Davis History and Risk Assessment
Dr. Simpson/Dr. Hakas New Patient Form
Dermatology Forms
Dermatology New Patient Packets - English
Dermatology New Patient Packets - Spanish
Endocrinology Forms
Endocrinology Questionnaire Form
Gastroenterology Forms
Patient Registration Form
Mammography Forms
To authorize the release of your mammography medical records, use one of the forms below.
If your previous mammogram was performed at Pinehurst Radiology Associates, please use this form:
If your previous mammogram was NOT performed at Pinehurst Radiology Associates, please use this form:
Pulmonology Forms
Pulmonology New Patient Packet - English
Pulmonology New Patient Packet - Spanish
Pulmonology and Sleep Medicine New Patient Questionnaire
Primary Care Forms
Primary Care Health Questionnaire
Rheumatology Forms
Rheumatology New Patient Packet - English
Rheumatology New Patient Packet - Spanish
Rheumatology New Patient Health Questionnaire
Sleep Medicine Forms
Insomnia New Patient Packet - English
