Form AOC-SP-914 "Release of Physical and Mental Health, Substance Abuse and Confidential Court Records for Concealed Handgun Permit" - North Carolina

What Is Form AOC-SP-914?

This is a legal form that was released by the North Carolina Court System - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2019;
  • The latest edition provided by the North Carolina Court System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AOC-SP-914 by clicking the link below or browse more documents and templates provided by the North Carolina Court System.

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Download Form AOC-SP-914 "Release of Physical and Mental Health, Substance Abuse and Confidential Court Records for Concealed Handgun Permit" - North Carolina

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RELEASE OF PHYSICAL AND MENTAL
STATE OF NORTH CAROLINA
HEALTH, SUBSTANCE ABUSE AND
CONFIDENTIAL COURT RECORDS FOR
County
CONCEALED HANDGUN PERMIT
G.S. 14-415.13(a)(5)
Name And Address Of Applicant
Date Of Birth
Social Security No.
State Drivers License No. (State Identification No. if no Drivers License)
State
I hereby authorize and require any and all doctors, hospitals or other providers who have ever provided physical or mental health or
substance abuse treatment or care to me, including without limitation the providers named below, to release to the sheriff of the above
named county any and all records concerning my physical capacity, mental health, mental capacity or substance abuse that the sheriff
may reasonably request in connection with my application for a concealed handgun permit. The purpose of the release is to enable the
sheriff to determine my qualification and competence to handle a handgun. I understand that alcohol and substance abuse information is
protected by federal regulations and that other confidential records such as psychiatric information may be protected by North Carolina
statute. Accordingly, I specifically authorize the release of any and all alcohol, substance abuse and psychiatric information that may be
documented in my records.
I understand that further disclosure or redisclosure by the sheriff of any information disclosed to the sheriff pursuant to this Release is
prohibited without my further written consent unless otherwise provided for by state or federal law. I understand that I may revoke this
authorization at any time except to the extent that action has already been taken in reliance on this Release. Even without my express
revocation, this Release will expire upon the satisfaction of the request or one year from the date below, whichever occurs first.
Name Of Provider
Address Of Provider
I also request and authorize any and all clerks of superior court of North Carolina to inform the sheriff of this County whether or not the
clerk’s records contain the record of any involuntary commitment proceeding under Article 5 of Chapter 122C of the General Statutes in
which I have been named as a respondent and, if so, to reveal to the sheriff any confidential information in the court files or records of
each such proceeding that the sheriff may reasonably require in order to determine whether or not to issue a concealed handgun permit
to me. This Release may be treated as a motion in the cause within the meaning of G.S. 122C-54(d) and a clerk may reveal information
to the sheriff pursuant to any specific or standing order entered in response to or anticipation of this motion.
I authorize the sheriff to photocopy this Release after I sign it, and I authorize any provider to whom a photocopy of this Release is
presented to rely on the photocopy as being as effective as the original.
NOTE: Pursuant to G.S. 14-415.15(a), no person, company, mental health provider, or governmental entity may charge additional fees to
the applicant for a concealed handgun permit for a background check under that subsection.
Date
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date
Signature Of Person Authorized To Administer Oaths
Signature Of Applicant
Title
Date Commission Expires
SEAL
AOC-SP-914, Rev. 2/19
© 2019 Administrative Office of the Courts
RELEASE OF PHYSICAL AND MENTAL
STATE OF NORTH CAROLINA
HEALTH, SUBSTANCE ABUSE AND
CONFIDENTIAL COURT RECORDS FOR
County
CONCEALED HANDGUN PERMIT
G.S. 14-415.13(a)(5)
Name And Address Of Applicant
Date Of Birth
Social Security No.
State Drivers License No. (State Identification No. if no Drivers License)
State
I hereby authorize and require any and all doctors, hospitals or other providers who have ever provided physical or mental health or
substance abuse treatment or care to me, including without limitation the providers named below, to release to the sheriff of the above
named county any and all records concerning my physical capacity, mental health, mental capacity or substance abuse that the sheriff
may reasonably request in connection with my application for a concealed handgun permit. The purpose of the release is to enable the
sheriff to determine my qualification and competence to handle a handgun. I understand that alcohol and substance abuse information is
protected by federal regulations and that other confidential records such as psychiatric information may be protected by North Carolina
statute. Accordingly, I specifically authorize the release of any and all alcohol, substance abuse and psychiatric information that may be
documented in my records.
I understand that further disclosure or redisclosure by the sheriff of any information disclosed to the sheriff pursuant to this Release is
prohibited without my further written consent unless otherwise provided for by state or federal law. I understand that I may revoke this
authorization at any time except to the extent that action has already been taken in reliance on this Release. Even without my express
revocation, this Release will expire upon the satisfaction of the request or one year from the date below, whichever occurs first.
Name Of Provider
Address Of Provider
I also request and authorize any and all clerks of superior court of North Carolina to inform the sheriff of this County whether or not the
clerk’s records contain the record of any involuntary commitment proceeding under Article 5 of Chapter 122C of the General Statutes in
which I have been named as a respondent and, if so, to reveal to the sheriff any confidential information in the court files or records of
each such proceeding that the sheriff may reasonably require in order to determine whether or not to issue a concealed handgun permit
to me. This Release may be treated as a motion in the cause within the meaning of G.S. 122C-54(d) and a clerk may reveal information
to the sheriff pursuant to any specific or standing order entered in response to or anticipation of this motion.
I authorize the sheriff to photocopy this Release after I sign it, and I authorize any provider to whom a photocopy of this Release is
presented to rely on the photocopy as being as effective as the original.
NOTE: Pursuant to G.S. 14-415.15(a), no person, company, mental health provider, or governmental entity may charge additional fees to
the applicant for a concealed handgun permit for a background check under that subsection.
Date
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date
Signature Of Person Authorized To Administer Oaths
Signature Of Applicant
Title
Date Commission Expires
SEAL
AOC-SP-914, Rev. 2/19
© 2019 Administrative Office of the Courts