Form DL-22 "Authority to Release Confidential Medical Report and Release of Claim" - North Carolina

What Is Form DL-22?

This is a legal form that was released by the North Carolina Department of Transportation - Division of Motor Vehicles - 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 January 1, 2017;
  • The latest edition provided by the North Carolina Department of Transportation - Division of Motor Vehicles;
  • 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 printable version of Form DL-22 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Transportation - Division of Motor Vehicles.

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Download Form DL-22 "Authority to Release Confidential Medical Report and Release of Claim" - North Carolina

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S
N
C
TATE OF
ORTH
AROLINA
D
T
EPARTMENT OF
RANSPORTATION
R
C
J
H. T
, III
OY
OOPER
AMES
ROGDON
G
S
OVERNOR
ECRETARY
DL-22 (Rev. 01/2017)
AUTHORITY TO RELEASE CONFIDENTIAL
MEDICAL REPORT AND RELEASE OF CLAIM
$10.00 Fee Required
(Check or Money order)
NC Division of Motor Vehicles
Medical Review Unit
3112 Mail Service Center
Raleigh, North Carolina 27697-3112
I,
, North Carolina Driver License Number
, hereby authorize the North Carolina Division of Motor Vehicles to
release and furnish a copy of my medical records and information to:
Name:
Street Address:
City and State:
I do hereby release, waive and relinquish all claims against the N. C. Division of Motor Vehicles,
its agents and employees, for any cause whatsoever arising out of the release of said medical
records to the above named individual.
Signature of Customer:
Date:
Signature of Parent/Guardian, if minor:
Date:
(customer name) personally came before
me this day and I acknowledge the due execution of the foregoing release.
This, the
day of
, 20
.
Signature of Notary or DMV Representative:
My commission expires:
.
(IMPRINT SEAL TO THE RIGHT)
Appropriate notarized release required prior to release of any medical documents.
Copies of accident records may be obtained by writing directly to: Traffic Records Section,
NC Division of Motor Vehicles, 3106 Mail Service Center, Raleigh, NC 27697-3106.
Mailing Address:
Location:
NC DIVISION OF MOTOR VEHICLES
Telephone: (919) 715-7000
DMV HEADQUARTERS BUILDING
PROCESSING SERVICES
1100 NEW BERN AVENUE
MEDICAL REVIEW UNIT
RALEIGH, NC 27697
Website: www.ncdot.gov
3112 MAIL SERVICE CENTER
RALEIGH, NC 27697-3112
S
N
C
TATE OF
ORTH
AROLINA
D
T
EPARTMENT OF
RANSPORTATION
R
C
J
H. T
, III
OY
OOPER
AMES
ROGDON
G
S
OVERNOR
ECRETARY
DL-22 (Rev. 01/2017)
AUTHORITY TO RELEASE CONFIDENTIAL
MEDICAL REPORT AND RELEASE OF CLAIM
$10.00 Fee Required
(Check or Money order)
NC Division of Motor Vehicles
Medical Review Unit
3112 Mail Service Center
Raleigh, North Carolina 27697-3112
I,
, North Carolina Driver License Number
, hereby authorize the North Carolina Division of Motor Vehicles to
release and furnish a copy of my medical records and information to:
Name:
Street Address:
City and State:
I do hereby release, waive and relinquish all claims against the N. C. Division of Motor Vehicles,
its agents and employees, for any cause whatsoever arising out of the release of said medical
records to the above named individual.
Signature of Customer:
Date:
Signature of Parent/Guardian, if minor:
Date:
(customer name) personally came before
me this day and I acknowledge the due execution of the foregoing release.
This, the
day of
, 20
.
Signature of Notary or DMV Representative:
My commission expires:
.
(IMPRINT SEAL TO THE RIGHT)
Appropriate notarized release required prior to release of any medical documents.
Copies of accident records may be obtained by writing directly to: Traffic Records Section,
NC Division of Motor Vehicles, 3106 Mail Service Center, Raleigh, NC 27697-3106.
Mailing Address:
Location:
NC DIVISION OF MOTOR VEHICLES
Telephone: (919) 715-7000
DMV HEADQUARTERS BUILDING
PROCESSING SERVICES
1100 NEW BERN AVENUE
MEDICAL REVIEW UNIT
RALEIGH, NC 27697
Website: www.ncdot.gov
3112 MAIL SERVICE CENTER
RALEIGH, NC 27697-3112
This Side Used by the Division of Motor Vehicles Only
Documents Released
Date
Number
Summary
Medical
Vision
Other/
Accident
OT/Rehab
Hearing/
of
/Rec
Report
Catch
Request/
Report
Report
Pages
Sheet
Form
All
Cancellation
1.
2.
3.
4.
5.
6
7.
8.
9.
10.
11.
12.
13.
Date
Number
Exemption/
Exemption
Self-
Hearing
Unsolicited/
of
Reconciliation
Other/
Certification
Evaluation
Unrequested
Pages
Sheet
Catch All
1.
2.
3.
4.
5.
6
7.
8.
Date
Number
Document Name
of
Pages
1.
2.
3.
4.
5.
6
7.
Method of Release: Copies given to customer/representative
Copies Mailed
Date of Release:
Released by:
DL-22 (Reverse)
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