HIPAA Authorization - North Carolina

Download HIPAA Authorization - North Carolina PDF

North Carolina · Fillable PDF · Free

Federal privacy law (HIPAA) limits who doctors, hospitals, and insurers can talk to about you. This authorization lets the people you name receive your health information so they can help you. Federal privacy law (HIPAA) limits who doctors, hospitals, and insurers can talk to about you. This authorization lets the people you name receive your health information so they can help you.

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Who this form is for

  • Federal privacy law (HIPAA) limits who doctors, hospitals, and insurers can talk to about you. This authorization lets the people you name receive your health information so they can help you.

What you'll need

  • Read the packet and check the receiving agency's required form.
  • Gather the names, dates and supporting records requested in the document.
  • Review the packet's signing, identification and witness instructions.

How to complete it

  1. Who and what (Page 1) Name the people who may receive your information and choose what may be released. Initial any specially protected records you want included.
  2. Sign before a notary (Page 2) Hospitals and insurers are more likely to accept a notarized authorization without question. Bring a current, government-issued photo ID.
  3. Give copies to the people you named and to your doctors and health plans.
  4. This form works best with a North Carolina Health Care Power of Attorney. We have a free form.

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These forms are a free convenience, not legal advice. First Choice Mobile Notary & Apostille is not a law firm. Consult an attorney licensed in the relevant state for legal questions.

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