Dhhs 4056 Patient Authorization English Spanish printable pdf download

_____________________________

NC Department of Health and Human Services

Last Name

First Name

Public Health Nursing and Professional Development

PATIENT AUTHORIZATION

Patient SS#: ________________________

to Permit Use and Disclosure of

Health Information

Date of Birth: ____/____/____

I am either the patient named above or the patient’s legally authorized representative.

By signing this form, I authorize

[1] Person or class of persons authorized to use or disclose the information

to use or disclose to

[2] Person or class of persons to whom use or disclosure would be made

the following protected health information

(identify the information in a specific and meaningful fashion):

The purpose of the use or disclosure is

[3] (describe each purpose of the requested use or disclosure):

I understand that, with certain exceptions, I have the right to revoke this Authorization at any time. If I

want to revoke this authorization, I must do so in writing. The procedure for how I may revoke the

authorization, as well as the exceptions to my right to revoke, are explained in

‘s

[4] Name of covered entity

Notice of Privacy Practices, a copy of which has been provided to me.

I understand that I may refuse to sign this authorization. I also understand that

[4] Name of covered entity

cannot deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility for

benefits if I refuse to sign this Authorization.

[5]

I understand that, once information is disclosed pursuant to this Authorization, it is possible that it will

no longer be protected by the federal medical privacy law and could be redisclosed by the person or

agency that receives it.

This authorization expires automatically upon

[6] Date or event that relates to the patient or the purpose of the use or disclosure

__________________________________________________________ ___________

Signature of patient OR authorized representative

Date

___________________________________________________________

Please print name of patient or authorized representative who signed above

[7] Please explain representative’s authority to act on behalf of the patient:

DHHS 4056-E (Revised 01/05)

PHNPD (Review 07/07)

Dhhs 4056 Patient Authorization English Spanish