HIPAA Authorization Form - North Carolina

HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (NORTH CAROLINA)

(Comprehensive — HIPAA, NC Mental Health/DD/SA Act, NC Communicable Disease Statutes, 42 C.F.R. Part 2)

1. DOCUMENT HEADER

HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Effective Date: [__/__/____]

2. DEFINITIONS

"Authorization" — This HIPAA authorization form, including any appendices.

"Covered Entity" or "CE" — The health-care provider, health plan, or health-care clearinghouse identified above, subject to HIPAA.

"Disclose" or "Disclosure" — The release, transfer, provision of access to, or divulging in any other manner of PHI outside CE, as those terms are used in 45 C.F.R. Section 160.103.

"HIPAA" — The Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, and its implementing regulations at 45 C.F.R. Parts 160 and 164.

"Individual" — The subject of the PHI and signatory hereto.

"PHI" — Protected Health Information, including the categories specifically identified in Section 3.1.

"Recipient" — The person(s) or entity(ies) authorized to receive PHI as set forth in Section 1.

"Use" — The sharing, employment, application, utilization, examination, or analysis of PHI within CE.

3. OPERATIVE PROVISIONS

3.1 Description of Information to Be Used or Disclosed

CE is authorized to Use and Disclose the following categories of PHI (check all that apply):

☐ Complete medical record
☐ Office/clinic visit notes for the period [__/__/____] through [__/__/____]
☐ Laboratory and diagnostic test results
☐ Diagnostic imaging and radiology reports
☐ Discharge summaries and consultation reports
☐ Billing and claims records
☐ Immunization records
☐ Other: [____________________________________________]

3.2 Authorized Recipient(s)

Disclosure may be made to: [Recipient Name / Title / Address / Phone].

3.3 Purpose of Use or Disclosure

PHI may be Used or Disclosed solely for the following purpose(s):
☐ Continuity of care / treatment by another provider
☐ Payment, claims, or insurance underwriting
☐ Legal proceedings — Case No. [____________]
☐ Disability or workers' compensation claim
☐ Research study titled [____________]
☐ At the request of the Individual
☐ Other: [____________________________________________]

3.4 Expiration

This Authorization expires on the earliest of:
(a) [__/__/____];
(b) completion of the purpose stated in Section 3.3; or
(c) revocation under Section 3.6.

If no date is supplied, this Authorization expires one (1) year from the Effective Date.

3.5 Conditioning Prohibited

CE may not condition treatment, payment, enrollment, or eligibility for benefits on the execution of this Authorization, except as expressly permitted by 45 C.F.R. Section 164.508(b)(4).

3.6 Right of Revocation

Individual may revoke this Authorization at any time by delivering signed written notice to CE at [Designated Privacy Office / Address]. Revocation is effective on receipt but does not affect actions taken by CE or Recipient in reliance on this Authorization before revocation.

3.7 Re-Disclosure Warning

Information disclosed under this Authorization may be re-disclosed by Recipient and may no longer be protected by HIPAA or North Carolina law. PHI Disclosed pursuant to N.C.G.S. Section 130A-143 (HIV/communicable disease) and 42 C.F.R. Part 2 (substance use disorder) must be accompanied by the written prohibition-on-redisclosure statement required by those laws. Unauthorized disclosure of MH/DD/SA confidential information is a Class 3 misdemeanor under N.C.G.S. Section 122C-52(e).

4. NORTH CAROLINA HEIGHTENED-PROTECTION CATEGORIES

The Individual specifically authorizes Disclosure of the following categories of sensitive information (initial only those authorized):

4.1 Mental Health, DD, and Substance Abuse Records (N.C.G.S. Section 122C-52 et seq.)

Confidential information acquired in attending or treating a client under Chapter 122C is not a public record and may not be disclosed except as authorized by N.C.G.S. Sections 122C-53 through 122C-56. A HIPAA covered entity that receives such information under those sections may further Use and Disclose it as permitted by the HIPAA Privacy Rule. By initialing the corresponding lines above, Individual authorizes Disclosure of the MH/DD/SA records described in Section 3.1.

4.2 HIV and Communicable Disease Information (N.C.G.S. Section 130A-143; Section 130A-148)

All information and records that identify a person who has or may have a reportable communicable disease — including HIV infection, AIDS, and AIDS-related conditions — are strictly confidential under N.C.G.S. Section 130A-143. Release is permitted only with the written consent of the person identified or as otherwise permitted by federal regulation. By initialing the HIV and communicable-disease lines above, Individual provides the written consent required by N.C.G.S. Section 130A-143(3).

4.3 Substance Use Disorder Records (42 C.F.R. Part 2)

Federally protected substance use disorder records may be Disclosed only when the Individual has specifically initialed the Substance Use line above and the Disclosure carries the Part 2 notice prohibiting redisclosure. This Authorization satisfies the written-consent requirements of 42 C.F.R. Sections 2.31 and 2.32 only to the extent the Individual has initialed the corresponding category.

4.4 Physician-Patient Privilege Waiver (N.C.G.S. Section 8-53)

The physician-patient privilege under N.C.G.S. Section 8-53 exists for the benefit of the Individual and may be waived only by the Individual. By executing this Authorization, Individual waives that privilege solely to the extent necessary to permit the Use and Disclosure described in Section 3, and only as to the Recipient(s) named in Section 1.

4.5 Peer Review Records (N.C.G.S. Section 90-21.4)

Medical peer review records are confidential under N.C.G.S. Section 90-21.4 and are not subject to disclosure by this Authorization. Nothing herein shall be construed to require CE to release records protected under that statute.

5. INDIVIDUAL RIGHTS AND ACKNOWLEDGMENTS

5.1 Right to a Copy. Individual is entitled to a signed copy of this Authorization upon request.

5.2 Right of Access. Individual retains the right of access to PHI under 45 C.F.R. Section 164.524 and to MH/DD/SA records as provided under Chapter 122C.

5.3 No Compensation for PHI. CE shall not receive remuneration for the Use or Disclosure of PHI except as permitted under HIPAA and North Carolina law.

5.4 Marketing and Sale. PHI may not be Used or Disclosed for marketing or sold to a third party unless a separate authorization expressly so provides.

5.5 Penalty Notice. Disclosure of confidential information to a person not authorized to receive it under N.C.G.S. Section 122C-52(e) is a Class 3 misdemeanor punishable by a fine not to exceed $500.

6. SIGNATURE AND EXECUTION

I have read this Authorization. I understand my rights described above, including my right to revoke this Authorization, the limits on re-disclosure, and the heightened protections applicable to sensitive information categories under North Carolina law. I am signing voluntarily.

Individual / Patient

Signature: _________________________________
Printed Name: _____________________________
Date: [__/__/____]

If Signed by Personal Representative

Signature: _________________________________
Printed Name: _____________________________
Authority (parent, guardian, agent under health-care power of attorney, executor): _____________________________
Documentation of Authority Attached: ☐ Yes ☐ No
Date: [__/__/____]

Witness (if required by facility policy)

Signature: _________________________________
Printed Name: _____________________________
Date: [__/__/____]

7. SOURCES AND REFERENCES

• 45 C.F.R. Section 164.508 — HIPAA core authorization elements
• N.C.G.S. Section 122C-52 — Right to confidentiality (MH/DD/SA)
• N.C.G.S. Sections 122C-53 through 122C-56 — Permissible disclosures
• N.C.G.S. Section 130A-143 — Confidentiality of communicable disease records
• N.C.G.S. Section 130A-148 — HIV testing and reporting
• N.C.G.S. Section 8-53 — Physician-patient privilege
• N.C.G.S. Section 90-21.4 — Medical peer review records
• 42 C.F.R. Part 2 — Confidentiality of substance use disorder patient records