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 - 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 July 1, 2020;
  • The latest edition provided by the North Carolina Department of Transportation;
  • 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.

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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. E
B
OY
OOPER
RIC
OYETTE
G
S
OVERNOR
ECRETARY
DL-22 (Rev. 07/2020)
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 27699-3112
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 27699-3106.
Mailing Address:
Location:
NC DIVISION OF MOTOR VEHICLES
Telephone: (919) 715-7000
DMV HEADQUARTERS BUILDING
CUSTOMER COMPLIANCE SERVICES
1100 NEW BERN AVENUE
MEDICAL REVIEW UNIT
RALEIGH, NC 27697
Website: www.ncdot.gov
3112 MAIL SERVICE CENTER
RALEIGH, NC 27699-3112
S
N
C
TATE OF
ORTH
AROLINA
D
T
EPARTMENT OF
RANSPORTATION
R
C
J. E
B
OY
OOPER
RIC
OYETTE
G
S
OVERNOR
ECRETARY
DL-22 (Rev. 07/2020)
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 27699-3112
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 27699-3106.
Mailing Address:
Location:
NC DIVISION OF MOTOR VEHICLES
Telephone: (919) 715-7000
DMV HEADQUARTERS BUILDING
CUSTOMER COMPLIANCE SERVICES
1100 NEW BERN AVENUE
MEDICAL REVIEW UNIT
RALEIGH, NC 27697
Website: www.ncdot.gov
3112 MAIL SERVICE CENTER
RALEIGH, NC 27699-3112