Anda di halaman 1dari 2

University of North Carolina at Chapel Hill, Campus Health Services CB # 7470, Chapel Hill, NC 27599-7470 (919) 966-2283, Fax

(919) 966-0616 ATTENTION: Health Information Management AUTHORIZATION FORM I authorize:

UNC Campus Health Services

OR

Name:________________________________________________________ Address:______________________________________________________ _____________________________________________________________ Fax:___________________ Phone:______________________

To use or disclose to (send information to):

UNC Campus Health Services

OR

Name:________________________________________________________ Address:______________________________________________________ _____________________________________________________________ Fax:___________________ Phone:______________________

Patient: Pick-up Mail to address below Fax:_______________________

The protected health information of: Patient Name:______________________________________________Date of Birth:______/______/________ Address:________________________________________City:____________State:____Zip Code __________ Telephone: (___) _______________________ PID #_____________________________________

Treatment Dates: ___________________________________________________________________________ Information to be disclosed (please check below to indicate information requested):
Clinic Notes Prescription History Physical Therapy Notes Orthopedic Notes Billing Records Immunization Records Pathology Report Lab Reports Entire Record (excludes CWS) Consultation(s) X-Ray Reports X-Ray Films Counseling and Wellness (CWS) Records Other:

I acknowledge that the data to be released MAY INCLUDE information protected by law. My initials below authorize inclusion of information pertaining to:
Mental Health Substance Abuse HIV/ AIDS, Other Reportable Diseases Genetic Testing Not Applicable

The purpose of the use or disclosure is:


Personal Use Continued Patient Care Parental/Guardian Communication Attorney/ Legal Insurance Other:

Continue on Reverse

I understand that: I may revoke this Authorization at any time: the revocation will not apply to information that has already been released in response to this Authorization I must revoke this Authorization in writing. The procedure for revoking this Authorization is to present my written revocation to the Health Information Management Department. I may refuse to sign this Authorization: UNC Campus Health Services will not condition my treatment, any payment, or eligibility for benefits on receiving my signature on this Authorization. a fee may be charged for copying the protected health information I have been informed and understand that information disclosed pursuant to this Authorization may be subject to redisclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no longer be protected under federal medical privacy law. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:___________________________________________________. If I fail to specify an expiration date or event or condition, this authorization will expire automatically in ninety (90) days from the date of signature. I have read and understand the information in this Authorization form.

Signature of Patient: Printed Name: OR Signature of Parent/Guardian: Printed Name: Date:

Date:

Office Use Only Request Approved Request Denied Date Completed: _________________________________________ Completed By:___________________________________________ Number of Pages Copied: ____________ Mailed Faxed Patient Pick-Up