[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-200558-105":3,"doc-detail-200558-en":81,"detail-sidebar-cat-1-en-105":96},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","privacy-release-form-authorization-to-disclose-health-information","Privacy Release Form - Authorization to Disclose Health Information","","North Carolina Department of Health and Human Services authorization form for disclosing specific health information. The client (or personal representative) authorizes a named provider or plan to release designated records to a specified recipient for stated purposes. The form explains expiration rules, the right to revoke (written revocation and verbal revocation sections), and consequences of failing to specify an expiration date. It also addresses protections against re-disclosure, special categories such as HIV/AIDS, substance abuse, psychological conditions, and refusal terms.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/privacy-release-form-authorization-to-disclose-health-information/200558/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/privacy-release-form-authorization-to-disclose-health-information/200558.png","ImageObject",442,249,{"name":42,"@type":43},"Logic","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-04",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",15,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who can authorize the disclosure of health information on this form?","Question",{"text":63,"@type":64},"The client or the client’s personal representative can authorize disclosure.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How does the form handle expiration of authorization?",{"text":68,"@type":64},"If no expiration date or condition is specified, it is valid for the time needed to fulfill the purpose for up to one year, except disclosures for financial transactions, which are valid indefinitely.",{"name":70,"@type":61,"acceptedAnswer":71},"Can the authorization be revoked, and how?",{"text":72,"@type":64},"Yes. The form allows revocation at any time and requires signing the revocation section on the back; it also includes a verbal revocation section.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},200558,1788509310,{"code":4,"msg":82,"data":83},"success",{"doc_id":79,"user_id":84,"nickname":42,"user_avatar":85,"doc_module":22,"category_id":86,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":87,"file_id":88,"file_url":89,"file_type":90,"file_size":91,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":92,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":93,"faqs":94,"seo_title":95,"seo_description":12,"update_tm":80,"read_time":22},1099513958762,"https://ap-avatar.wpscdn.com/avatar/1000023916a998db790?x-image-process=image/resize,m_fixed,w_180,h_180&k=1784791008015729253",17,"North Carolina Department of Health and Human Services  \nAUTHORIZATION TO DISCLOSE HEALTH INFORMATION  \nClient Name   Date ofBirth   \nClient Medical Record \\#  Client SS \\# (Optional)   \nI   hereby authorize  \n(Client or Personal Representative)  \n   to disclose specific health information  \n(Name of Provider/Plan)  \nfrom the records of the above named client to:    \n(Recipient Name/Address/Phone/Fax)  \nfor the specific purpose(s) :   \nSpecific information to be disclosed:    \nI understand that this authorization will expire on the following date, event or condition:    \nI 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 and that I will be asked to sign the Revocation Section on the back of this form. I further understand that any action taken on this authorization prior to the rescinded date is legal and binding.  \nI 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.  \nI 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 disclosure 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.  \nI further understand that I may request a copy of this signed authorization.  \n(Signature of Client) (Date) (Witness-If Required)  \n(Signature of Personal Representative) (Date) (Personal Representative Relationship/Authority)  \n**********  \nNOTE: This Authorization was revoked on      \n(Date) (Signature of Staff)  \nDHHS-1000 (1/03)  \nAuthorization to Disclose Health Information  \nNorth Carolina Department of Health and Human Services  \nREVOCATION SECTION  \nI do hereby request that this authorization to disclose health information of    \n(Name of Client)  \nsigned by  on    \n(Enter Name of Person Who Signed Authorization) (Enter Date of Signature)  \nbe rescinded, effective   . I understand that any action taken on this authorization prior to the  \n(Date)  \nrescinded date is legal and binding.  \n(Signature of Client) (Date) (Signature of Witness) (Date)  \n(Signature of Personal Representative) (Date) (Personal Representative Relationship/Authority)  \nVERBAL REVOCATION SECTION  \nI do hereby attest to the verbal request for revocation of this authorization by    \n(Name of Client or Personal Representative)  \non   . The client or his personal representative has been informed that any action (Date)  \ntaken on this authorization prior to the rescinded date is legal and binding.  \n(Signature of Staff) (Date) (Signature of Witness) (Date)  \nDHHS-1000 (1/03)  \nAuthorization to Disclose Health Information","cbCaiuDNEU3YbTae","https://ap.wps.com/l/cbCaiuDNEU3YbTae","pdf",105817,"English","# AUTHORIZATION TO DISCLOSE HEALTH INFORMATION\n## Purpose, recipient, and specific information\n## Expiration and right to revoke\n## Re-disclosure and sensitive information\n# REVOCATION SECTION\n## Written revocation\n## Verbal revocation","[{\"question\":\"Who can authorize the disclosure of health information on this form?\",\"answer\":\"The client or the client’s personal representative can authorize disclosure.\"},{\"question\":\"How does the form handle expiration of authorization?\",\"answer\":\"If no expiration date or condition is specified, it is valid for the time needed to fulfill the purpose for up to one year, except disclosures for financial transactions, which are valid indefinitely.\"},{\"question\":\"Can the authorization be revoked, and how?\",\"answer\":\"Yes. The form allows revocation at any time and requires signing the revocation section on the back; it also includes a verbal revocation section.\"}]","Privacy Release Form - Authorization to Disclose Health Information | PDF",{"code":4,"msg":82,"data":97},[98,103,108,113,117,122,125,130,135],{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},11,"Presentations",90,"presentations",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},12,"Resumes",80,"resumes",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},14,"Invoices",70,"invoices",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},"Posters",60,"posters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},16,"Social Media",50,"social-media",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":123,"slug":124},40,"forms",{"id":126,"doc_module":22,"doc_module_name":25,"category_name":127,"show_sort_weight":128,"slug":129},18,"Letters",30,"letters",{"id":131,"doc_module":22,"doc_module_name":25,"category_name":132,"show_sort_weight":133,"slug":134},21,"Paper Templates",5,"papers-templates",{"id":136,"doc_module":22,"doc_module_name":25,"category_name":137,"show_sort_weight":4,"slug":138},158,"General","general-158"]