Authorization to Disclose Protected Health Information
Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information. This form implements the requirementsfor consumer authorization to use and disclose health information protected by the federal health privacy law (45 C.F.R. parts 160, 164),
the federal drug and alcohol confidentiality law (42 C.F.R part 2), and state confidentiality law governing mental health, developmental disabilities, and substance abuse services (G.S.122C). Covered entities must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorities by law. Covered entities may use this form or any other form that complies with HIPAA, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this
authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.