Physician Order/ Referral Form

Audiology and Hearing Services Forms

Medical Records

All client and patient care information at Clarity is regarded as confidential and available only to authorized users. Medical records will be obtained from other health care facilities when requested by a doctor and upon written authorization of the patient.

Please complete the Release of Information Authorization below if,

1) You would to like to us to send a request that your records be released to Clarity from another facility

or

2) You would like us to release your Clarity records to another entity

Please include a copy of a photo ID with your Release of Information Authorization request. Please note that we will not be able to process Release of Information Authorization requests if the form is not completed in entirity.

By Email: info@clarityupstate.org

By Mail: Clarity, Inc
Attention: Medical Records
29 North Academy Street
Greenville, SC 29601

By Fax: (864) 331-1416