North Carolina Health and Human Services Authorization Form
This file is an authorization form from the North Carolina Department of Health and Human Services that allows the disclosure of health information. It includes sections for client details, the recipient of the information, and the purpose of disclosure. The form also contains provisions for revoking the authorization.
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How do I fill this out?
To fill out this form, you will need to provide specific details about the client and the recipient of the health information. Ensure all required fields are completed accurately. Sign and date the form to authorize the disclosure.
How to fill out the North Carolina Health and Human Services Authorization Form?
1
Enter client and recipient details.
2
Provide the purpose of disclosure.
3
Specify the information to be disclosed.
4
Sign and date the form.
5
Return the completed form to the appropriate party.
Who needs the North Carolina Health and Human Services Authorization Form?
1
Patients who need to authorize the release of their health information.
2
Healthcare providers requesting patient consent for information disclosure.
3
Insurance companies requiring health information for claims processing.
4
Legal representatives managing client health records.
5
Researchers requiring access to health data for studies.
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What are the instructions for submitting this form?
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.
What are the important dates for this form in 2024 and 2025?
There are no specific dates provided for this form for 2024 and 2025. Ensure you check for any updates or changes annually.
What is the purpose of this form?
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.
Tell me about this form and its components and fields line-by-line.
- 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.
What happens if I fail to submit this form?
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.
How do I know when to use this form?
- 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.
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