STATE OF NORTH CAROLINA RELEASE OF PHYSICAL AND MENTAL HEALTH, SUBSTANCE ABUSE AND CONFIDENTIAL COURT RECORDS County FOR CONCEALED HANDGUN PERMIT 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 of 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 clerks 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. Any expenses relating to the search, production, copying and certification of a medical or court record pursuant to this Release shall be my responsibility. 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. Date SWORN AND SUBSCRIBED TO BEFORE ME Date Signature Of Person Authorized To Administer OathsSignature Of Applicant Title Date Commission Expires SEAL AOC-SP-914M, New 12/95, 1997 Administrative Office of the Courts