Lisa Hawkins

Inspirational Job Title with excellent sales record and history of effective leadership. Strong reputation for developing rapport with customers and increasing repeat business for department and store. Consistently motivates cosmetics team to meet sales goals.

Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.

To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.

Hardworking and passionate job seeker with strong organizational skills eager to secure entry-level Job Title position. Ready to help team achieve company goals.

• I give permission to release the health information of: (One patient per form)
• Patient Name: Date of birth:
• Street Address: Last 4 numbers of SSN:
• City, State, Zip: Telephone: ( )
• Email address:
• Although Novant Health will use reasonable means to protect the security and confidentiality of emails sent and received, we cannot guarantee the security and confidentiality of all email communications
• Release Information From: Release Information To: (list applicable Facility(s) and/or Practice(s)) (Name of facility, person, company) (Relationship) (Street address or PO Box, City, State, Zip code) (Phone number) (Fax number)
• Purpose of Release (check reason): Request of individual / personal Insurance Disability Workers Compensation
• Legal purpose including discussions & proceedings Other:_______________________________________________________
• Must fill in dates of treatment for records to be released: Treatment dates FROM:___________________ TO:___________________
• Hospital (check all that may apply): Office/Clinic (check all that may apply):
• Hospital Abstract Office / Clinic Abstract
• History & Physical Progress Notes Office Visits
• Discharge Summary Emergency Record Physical Exam
• Operative Reports Cardiac Reports/EKG Consultation Reports
• Consultation Reports Laboratory Reports Diagnostic Test Results
• Diagnostic Test Results Radiology/X-Ray Reports Laboratory Reports
• Medications Pathology Reports Radiology Reports
• Allergies Billing Information Medications
• Physician Orders Other:__________________ Billing Information
• Other:________________________________
• Entire Record (not including psychotherapy notes) Entire Record (not including psychotherapy notes)
• Format (only select one): Delivery Method:
• Paper copy (charges may apply) Electronic copy Reg
• US Mail Pick-up Email Fax
• CD (charges may apply) Other: _____________________________ Other:______________________________
• 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, unless limited by the above selections
• 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
• 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
• I have a right to receive a copy of this form upon request
• This permission expires 90 days after the date of my signature unless another date or event is written here:___________________
• Signature: Print name: Date/Time:
• 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 Guardian Executor/Administrator/Attorney in Fact Parent Next of Kin

• 900010 , R 7/03/2015