Hipaa Form 1a - Authorization To Release Medical Records

AUTHORIZATION for USE, DISCLOSURE and/or

REQUEST of PROTECTED HEALTH INFORMATION

1920 South 16

Street

Wilmington, NC 28401

Phone: 910-341-3308

Fax Release Form to: 910-341-3419

Fax Records to: 910-341-1900

Check if this authorization is for psychotherapy notes.

SECTION A: Psychotherapy Notes.

If this

authorization is for psychotherapy notes, you must not use it as an authorization for any other type of protected health

information. Identify the psychotherapy notes by checking “Other” in Section C and describing in the space provided, do

not check any other boxes or types of information.

SECTION B: The Individual (or the Individual’s Personal Representative) confirming the

authorization.

I authorize the use and/or disclosure of my protected health information as described in Section C below. I

understand that this authorization is voluntary.

I understand that, if the persons or organizations I authorize below are not health care providers, they may further disclose the

protected health information and it may no longer be protected by federal health information privacy laws.

Patient’s Name: ________________________________________________________________________

Address: ______________________________________________________________________________

City: ___________________________________ State: __________ Zip Code: _____________________

Telephone: _________________________ E-mail: ___________________________________________

Date of Birth: ______________________ Social Security # (last 4 digits only): __________________

SECTION C: The use, disclosure and/or request being authorized (minimum necessary).

 Present year only  1 year  2years History/Office Notes

 Present year only  1 year  2years Labs

 Last Eye Exam

 Last Foot Exam

2 years Pap Smears  2 yrs Mammograms  All Immunization summaries

All Colonoscopy and EGD procedure reports  All Pathology reports

 All Radiologic studies (Bone Density, CT/CTA, MRI/MRA, US, Vascular, etc)

 All Cardiac Studies

All Hospital Admissions, H&Ps, Consults, Operative reports, Discharges

 Other (Please be specific and DO NOT request ALL Records)

_________________________________________________________________________________

Entities Authorized to Use or Disclose:

Entities Authorized to Receive and Use:

Records requested FROM:

Records to be SENT TO:

Name of provider/organization:

Name of provider/organization/person:

______________________________________

___________________________________________

Address _______________________________

Address_____________________________________

______________________________________

____________________________________________

Phone #: _________________________

Phone #: ___________________________

Fax #: ___________________________

Fax #: _____________________________

HIPAA Form 1A (Revised 12/2013)

Page 1 of 2 Pages

Hipaa Form 1a - Authorization To Release Medical Records - 2013

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