To submit this form, you can send it via email, fax, or mail. Email the completed form to the appropriate recipient at their provided email address. Fax the form to the recipient's fax number, or mail it to their physical address. Ensure all information is accurate and the form is signed before submission. For questions or assistance, contact the recipient directly.

There are no specific dates provided for this form for 2024 and 2025. Ensure you check for any updates or changes annually.

The purpose of this form is to authorize the disclosure of specific health information from the North Carolina Department of Health and Human Services. By completing this form, clients can specify what health information is to be disclosed, to whom, and for what purpose. Additionally, the form includes a section for revoking the authorization, ensuring that clients have control over their health information.

• 1. Client Name: The full name of the client whose health information is being disclosed.
• 2. Date of Birth: The client's date of birth for identification purposes.
• 3. Client Medical Record #: The client's medical record number to locate and identify their health records.
• 4. Client SS # (Optional): The client's Social Security Number, which is optional.
• 5. Client or Personal Representative Name: The name of the client or their personal representative authorizing the disclosure.
• 6. Name of Provider/Plan: The name of the healthcare provider or plan holding the client's records.
• 7. Recipient Name/Address/Phone/Fax: Details of the recipient who will receive the disclosed health information.
• 8. Specific Purpose(s): The specific purpose for which the health information is being disclosed.
• 9. Specific Information to be Disclosed: Details about the specific health information to be disclosed.
• 10. Expiration Date/Event/Condition: The date, event, or condition upon which the authorization will expire.
• 11. Signature and Date: The signatures and dates of the client, personal representative, and witness (if required).
• 12. Revocation Section: Section for rescinding the authorization, including the client's and witness's signatures and dates.
• 13. Verbal Revocation Section: Section to document verbal requests for revocation, including staff and witness signatures and dates.

Failing to submit this form may result in the inability to disclose necessary health information. This can impact treatment, payment, and other services that require authorized health information.

• Delayed Treatment: Your healthcare provider may not receive the required information in time, leading to treatment delays.
• Payment Issues: Insurance claims may be denied or delayed if required health information is not disclosed.
• Service Denial: Requested services that depend on disclosed health information may be denied.

• 1. Healthcare Provider Requests: Authorize your healthcare provider to share your health information with other medical professionals.
• 2. Insurance Claims: Provide necessary health information to your insurance company for claims processing.
• 3. Legal Purposes: Authorize the release of health information for legal matters.
• 4. Research Participation: Allow researchers to access your health data for study purposes.
• 5. Personal Records Management: Manage and share your health records with chosen representatives.