Form Dma-7097 - Request And Authorization To Disclose Health Information - North Carolina

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I________________________________________________ hereby request the North Carolina Division of
(Name of recipient or Authorized Representative
Medical Assistance to disclose a Medicaid profile containing claim information for services billed to and
paid by Medicaid from the records of the person(s) listed below for this purpose:
Recipients Name
SSN or Medicaid ID Number
Dates of Service
I understand records will be sent to:
I understand this authorization will expire on this date, event or condition
I understand that if I fail to specify an expiration date or condition, this authorization is valid for the
period of time needed to fulfill its purpose for up to one year, except for disclosures for financial
transactions, wherein the authorization is valid indefinitely. I also understand that I may revoke this
authorization at any time upon my written authorization. I further understand that any action taken on
this authorization prior to the rescinded date is legal and binding.
I understand that my information may not be protected from re-disclosure by the requester of the
information; however, if this information is protected by the Federal Substance Abuse Confidentiality
Regulations, the recipient may not re-disclose such information without my further written authorization
unless otherwise provided for by state or federal law.
I understand that if my record contains information relating to HIV infection, AIDS or AIDS-related
conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing this will
include that information. I also understand that I may refuse to sign this authorization and that my
refusal to sign will not affect my ability to obtain treatment, payment for services, or my eligibility for
benefits; however, if a service is requested by a non-treatment provider (e.g., insurance company) for the
sole purpose of creating health information (e.g., physical exam), service may be denied if authorization is
not given. If treatment is research-related, treatment may be denied if authorization is not given. I
further understand that I may request a copy of this signed authorization.
Individual authorizing disclosure
SIGNATURE __________________________________________________DATE:____________________
WITNESS SIGNATURE (if required) ______________________________DATE: ___________________
If not signed by subject of disclosure, specify basis for authority to sign
Parent of minor
Authorized Representative
Telephone Number
DMA-7097 (11/2007)


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Parent category: Legal