AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
UNDER FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996
I hereby authorize the use or disclosure of my individually identifiable health information as described below.
I understand that this authorization is voluntary. I understand that if the organization authorized to receive the
information is not a health plan or health care provider, the released information may be subject to re-disclosure
and may no longer be protected by federal privacy regulations, including HIPAA. I hereby release the
organization providing this information from any legal responsibility or liability for disclosure of this information
to the extent indicated and authorized herein.
Patient Name:_____________________________________________ ID/SS #: _________________________
Patient Address: _________________________________________________ Date of Birth: _____/____/____
Persons/organizations providing the information: _______________________________________________
(Medical Provider Name/VA Hospital or Clinic)
Persons/organizations receiving the information: (Send to)
North Carolina Heroes Fund
PO Box 652, Pineville, NC 28134
Specific description of information, covering health care from to___________________________________:
Complete health records and bills (prescription bills, history and physical, discharge summary, operative reports,
consultation reports, radiology and imaging reports), excluding all images (x-rays, photographs, etc.)
Other (please specify) _____________________________________________________________________
The patient or the patient’s representative must read and initial the following statements:
1. I understand that this authorization will expire on six month after date of signing this form.
2. I understand that I may revoke this authorization at any time by notifying the providing organization in writing and
that, if I do revoke this authorization, this will not have any effect on any action the providing organization takes
before receiving the revocation.
3. I understand that I have the right to refuse to sign this Authorization.
4. I 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 will no
longer be protected under federal medical privacy law. Initials: ___________
5. I understand the data release may include material protected by law including Mental Health, Drugs and
Alcohol, HIV/AIDS and other communicable diseases and Genetic Testing. Initials:___________
I have read and understand the
information in this Authorization.
_________________________________________________ Date: __________________________
Signature of patient or designated representative
(Form MUST be completed before signing).
YOU MAY REFUSE TO SIGN THIS AUTHORIZATION