Patient Forms

New Patient Enrollment (Required for Assisted or Independent Living patients only)

The New Patient Enrollment forms can be completed online via DocuSign or by downloading the packet. The packet will also include "Patient Information", "Patient History", "Acknowledgement of Receipt of Notice of Privacy Practices", Authorization for the Use or Disclosure of Protected Health Information", and "HIPAA Authorization to Release Protected Health Information".

Please note when completing the New Patient Enrollment forms, you will need to gather specific documents.

New Patient Enrollment

Billing Statement and Disclosure

Please review Summit Medical Carolinas' Billing Statement and Disclosure for important billing information.

Download Billing Statement and Disclosure

Insurance

Summit Medical Carolinas accepts Medicare, Medicaid, and many major insurances.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Download Notice of Privacy Practices

HIPAA Authorization to Release Protected Health Information (PHI) / Medical Records Request

To request a copy of your medical records or to release a copy of your medical records to a third party, complete the this form and mail or fax to Summit Medical Carolinas.

Submit the completed form via mail or fax to:

Summit Medical Carolinas

9935-D Rea Road, Suite 324

Charlotte, NC 28277

Fax: 980-580-4749

HIPAA Authorization to Release Protected Health Information