MECKLENBURG NEUROLOGICAL ASSOCIATES, P.A.
1900 Scott Avenue
Charlotte, NC 28203
October 3, 2018
Re: Important Notice Regarding Closure of Mecklenburg Neurological Associates, P.A. – Your Action Required
Dear Patient:
It has been my privilege to care for you during my time at Mecklenburg Neurological Associates, P.A. (“MNA”). However, as you may know, effective April 13, 2018, I will be leaving MNAto accept a teaching position and will no longer have an office for the practice of medicine in the State of North Carolina. Therefore, you do not have the option to continue to receive care from me after April 13, 2018.
In addition, at the same time, a business decision has been made to close the office of MNA located at 1900 Scott Avenue, Charlotte, North Carolina 28203, effective April 13, 2018. After that date, MNA will not continue to provide patient care services at any location and all of its physicians and other providers will be relocating.
Therefore it is important that you follow the instructions in this letter to ensure continuity of your care.
You must select a new physician to provide your care. I have been working with my patients to transition their care to one of the other physicians of MNA who will be relocating their practices to other offices in North Carolina or to physicians outside of MNA. You have the right to choose your healthcare provider, and we are committed to fully supporting your decision. If I have not discussed with you my recommendations for other physicians who may be able to care for you following my departure, please contact Melinda Stevens at MNA at the contact information listed below.
If you have elected to receive care from another MNA physician at his new practice location, your records will be transferred to that physician as of April 13, 2018. If you have chosen instead to receive care from a non-MNA physician, please complete and return the enclosed Authorization to Release Information form to the MNA office in person, electronically, or by mail by April 13, 2018, so that MNA can arrange to transfer your records to that new physician. You can also obtain copies of your patient records via your patient portal if you have one, which we anticipate will be available until September, 2018.
Please contact Melinda Stevens at or or 704-334-7311 if you have any questions or concerns or need assistance with obtaining or transferring your patient records.
Thank you for your patience and understanding during this transition. I extend to you my best wishes for your future health and happiness.
Sincerely,
______
Robert Nahouraii, M.D.
[ENCLOSED AUTHORIZATION FORM]
Patient Information: I give permission to release the health information of: (One Patient Per Form)
Patient Name:______
Date of Birth:______Last 4 numbers of SSN_____
Street Address:______
City, State, Zip:______
Telephone:______
Email address:______
By providing your email address you acknowledge and accept the risks outlined in the Guidelines for E-mail with Patients, posted on carolinashealthcare.org.
Release Information Form:
Mecklenburg Neurological Associates, P.A.
1900 Scott Avenue, Charlotte, NC 28203
Phone number: (704) 334-7311 Fax number: (704) 335-9790
Release Information To:
______(Name of facility, person, company)
______(Street Address or PO Box, City, State, Zip Code)
______
(Phone number) (Fax number)
PURPOSE OF RELEASE (check reason):___ Request of individual/personal
X Continued patient care ___Insurance ___Legal purpose including discussions & proceedings ___ Other
Fill in dates of treatment for records to be released:
Treatment dates: From______To Present______
Facility Summary: May include history & physical, discharge summary, operative notes, consults, diagnostic test results, medication list, allergies. Office/Clinical Summary: May include most recent office visits, physical exam, consults, diagnostic test results. ______
Facility (check all that may apply):
__ Facility Summary
__Discharge Summary __ Emergency Record
__History and Physical __Cardiac Reports/EKG
__ Consultation reports __ Other
__ Operative Reports
__ Laboratory reports
__Radiology/X-Ray Reports
__Pathology reports
__Entire record (Not including psychotherapy notes)
__Itemized Bill
______
Office/Clinic/Home Care (check all that may apply):
__Office/Clinical Summary
__Office/Home Visits
__ Physical Exam
__Laboratory Reports
__Radiology Reports
Other______
__Entire Record (Not including psychotherapy notes)
__Itemized Bill
______
Behavioral Health/Sub. Use (check all that may apply):
__Facility Summary
__Clinical/Discharge Summary
__Assessments
__Physician Orders
__Progress/Therapy Notes
__Medications
__Lab reports
__Other all other records of treatment, including psychotherapy notes
__Entire Record (Not including psychotherapy notes)
__Itemized Bill
______
FORMAT:
__CD (charges may apply)
__Email Address noted above, where permitted
__Paper copy (charges may apply)
__Other
______
DELIVERY METHOD:
__Reg.US Mail __ Pick-up __ Fax, where permitted
__Overnight/Express Mail Service, where permitted
__Secure email
__Other: ______
PATIENT’S RIGHTS – I understand that:
I can cancel this permission at any time. I must cancel in writing and send or deliver cancellation to releasing facility or practice named above. Any cancellation will apply only to information not yet released by facility or practice.
This is a full release including information related to behavioral/mental health, drug and alcohol abuse treatment (in compliance with 42 CFR Part 2), genetic information, HIV/AIDS, and other sexually transmitted diseases.
Once my health information is released, the recipient may disclose or share my information with others and my information may no longer be protected by federal and state privacy protections. MNA may also release protected health information in accordance with its Notice of Privacy Practices.
Refusing to sign this form will not prevent my ability to get treatment, payment, enrollment in health plan, or eligibility for benefits.
A fee may be charged for providing the protected health information.
This permission expires one year after the date of my signature unless another date or event is written here:
______
Signature:______
Print Name:______
Date: ______
Note: If the patient lacks legal capacity or is unable to sign, an authorized personal representative may sign this form.
Note the relationship/authority if signature is not that of the patient (Written Proof May be Requested):
__Healthcare Agent/POA
__Parent
__Guardian
__Adult Child
__Executor/Administrator/Attorney in Fact __Spouse
__Affidavit Next of Kin __Other:
Note: If minor consented for their outpatient treatment for pregnancy, sexually transmitted disease or behavioral/mental health without parental consent, the minor must sign this authorization. When the patient is a minor being treated for substance abuse, the minor must sign this authorization, regardless of who consented for treatment.
Signature: ______
Print Name: ______
Date: ______
Authorization given to patient / Date of release:______via ___ Mail __Fax __Other
__ID Verified
__DL/Other ID
Employee Name: ______
Date: ______
Patient Information or Sticker
Name:
DOB:
Medical Record #: Account #:
CHAR1\1580667v2