For your convenience, you can download the forms you’ll need for admission to Pavillon, as well as other documents that may be helpful or informative. 

How to Request Your Medical Records:

  1. Complete and sign the Medical Records Authorization to Release Information form. Failure to complete the form in its entirety may cause unnecessary delays in obtaining the copy of the record. The completed form must have the signature of the patient to be processed. 
Forms & Documents for Pavillon Treatment Center


Download the Medical Records Authorization to Release Information form.

  1. Please return the completed form via fax, standard mail, or a courier service, such as FedEx or UPS. These forms are not accepted via email. 

If sending via standard mail or a courier service, please use the following address: 

Pavillon 

Medical Records Department 

241 Pavillon Place 

Mill Spring, NC 28756 

If faxing, please use our Medical Records Department’s fax number: 1-888-480-4691 

  1. There is a minimum fee of $10.00 to process each request (NC GS 90-411). The cost for processing the request is as follows: 
  • 75 cents per page for the first 25 pages 
  • 50 cents per page for pages 26 through 100 
  • 25 cents per page for pages over 100 

If the number of pages is fewer than 25, the minimum fee will be charged. 

  1. As soon as the cost for processing the request has been determined, the Medical Records Department will contact the requestor with payment options. 
  2. Records will be sent as soon as payment is received. Please allow up to 30 days to for requests to be processed. 

Other resources on this site: