Authorization Form For Use & Disclosure Of Protected Health Information - 2012
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1AUTHORIZATION FOR USE & DISCLOSURE OF
PROTECTED HEALTH INFORMATION
DEPARTMENT OF PUBLIC HEALTH
1235 Ramsey Street
Fayetteville, NC 28301
I authorize the Cumberland County Department of Public Health to release the noted protected health information from the
medical records of the patient listed below:
Patient’s Name: ___________________________________
Date of Birth: ____/____/___ SS# _____-______-_______
Last Name
First Name
MI
To the agency or individual indicated below:
Facility/Person _____________________________________________
Telephone Number: _____________________
Street Address _____________________________________________
Fax Number: _____________________
City/Zip Code: ____________________________________________
Attn: _________________________________
To include the following information:
Progress Notes
Discharge Summary
Radiology Report
History & Physical
Family Planning Records
Communicable Disease
(STD, HIV, TB records)
Laboratory Reports (Please specify) _______________________________________________________________
Information contained in the patient’s medical record related to psychiatric and/or psychological diagnosis, status,
symptoms, prognosis, and treatment to date.
Other: _____________________________________________________________________________
For the Purpose of:
Sharing with other Health Care Provider Continuity of Care
Insurance Processing
Legal reasons
Immediate Care (Patient in Office, please fax)*
Personal use
Other ______________________________________________________________________________________
The above information to be disclosed by:
In office request
Fax
Mail
Email
*If Patient requests records to be faxed/emailed ________________________________________________/______________
Signature of Patient/Authorized Representative Required
Date
Statement Notice: I understand that with certain exceptions, I have the right to revoke this Authorization at any time. If I want to revoke this
authorization, I must do so in writing. The procedure for how I may revoke the authorization as well as the exceptions to my right to revoke are
explained in the Notice of Privacy Practices, a copy which has already been provided to me and I understand that I may refuse to sign this
authorization. I also understand that the Cumberland County Department of Public Health cannot deny or refuse to provide treatment, payment,
enrollment in a health plan, or eligibility for benefits if I refuse to sign this authorization. I understand that once the information is disclosed
pursuant to this Authorization, it is possible that it will no longer be protected by the federal medical privacy law and could be redisclosed by the
person or agency that receives it. If you are requesting to receive your Protected Health Information electronically, we want to inform you that
email communication can be intercepted in transmission by, or misdirected to a third-party. Cumberland County Department of Public Health is not
liable for any damages resulting from the interception or misdirection of electronically transmitted PHI.
This authorization expires automatically upon 60 days, after the date signed.
Authorization Signature Required:
__________________________________________
_______________________________
_____________________
Signature of Patient/Authorized Legal Representative
Relationship to Patient
Date
CCDPH 8/2012
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