Dear Patients,

I am writing to inform you that I am closing my practice, effective immediately, due to an acute medical condition. I would like to thank you for the trust you have given me over the years as your physician. Taking care of you has been an honor for me.

It is important that you continue obtaining medical care. Therefore, you should establish contact with another physician immediately. Below is a list of new providers and their contact information. In addition, below are instructions on how to transfer your medical records to your new physician. Until you have an appointment with a new provider, please reach out to your primary care physician or OB/GYN for prescription refills.

All medical records are confidential and protected by federal privacy and security regulations. With your authorization, a copy of your medical records can be transferred to another physician. The HIPAA-compliant authorization form is necessary to release a copy of your medical records to your new physician. Please complete the form and return it by email charlotteintegrative@gmail.com after establishing care with a new provider. On receipt of this signed form, my office will forward a copy of your medical records to the physician you designate.

Please note that transfer of patient records may take up to 30 days.

Your records will be retained for up to 4 years, after which they will be destroyed in accordance with HIPAA regulations. Note: if you request your records after 6 months of receiving this letter, you may be charged $50 for transfer of your records.

Again, I want to thank you for the privilege of working with you over the years.

Sincerely,
Dr. Joy Ross

4334 Yoruk Forest Lane
Charlotte, NC 28211

p: 704-295-1880
f: 980-202-0296
e: charlotteintegrative@gmail.com

MEDICAL RECORDS RELEASE FORM

Authorization to Release Medical Records

POTENTIAL PROVIDERS