Medical Records Authorization (HIPAA)

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA) — NORTH CAROLINA

This Authorization is executed in connection with a personal-injury matter so that the Patient and/or the Patient's attorney may obtain the Patient's medical records.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following health-care provider(s), facility(ies), clinic(s), pharmacy(ies), laboratory(ies), insurer(s), or custodian(s) of records to release the Protected Health Information ("PHI") described below:

3. RECIPIENT(S) — PERSON(S) AUTHORIZED TO RECEIVE RECORDS

4. RECORDS AUTHORIZED FOR RELEASE

Date range of records: [__/__/____] to [__/__/____] (or ☐ all dates).

Check each category of records to be released:

• ☐ Complete medical record / designated record set
• ☐ History and physical examination reports
• ☐ Office/progress/treatment notes
• ☐ Hospital and emergency department records
• ☐ Operative and surgical reports
• ☐ Physician orders
• ☐ Laboratory and pathology reports
• ☐ Radiology/imaging reports and films (X-ray, MRI, CT, mammogram, ultrasound)
• ☐ Physical therapy / rehabilitation records
• ☐ Prescription and pharmacy/medication records
• ☐ Billing statements, itemized charges, and payment records
• ☐ Diagnostic test results
• ☐ Discharge summaries
• ☐ Other (specify): [________________________________]

5. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

The following categories are protected by heightened confidentiality rules. They will NOT be released unless the Patient specifically initials the corresponding line below. My initials authorize release of that specific category to the Recipient(s) named in Section 3:

42 C.F.R. Part 2 notice (substance use disorder records): "42 CFR part 2 prohibits unauthorized use or disclosure of these records." Each disclosure made with the patient’s written consent must also be accompanied by a copy of the consent or a clear explanation of its scope. See 42 C.F.R. § 2.32.

6. PURPOSE OF DISCLOSURE

The purpose of this disclosure is:

• ☐ Legal representation / evaluation, prosecution, or settlement of the Patient's personal-injury claim
• ☐ At the request of the Patient
• ☐ Other (specify): [________________________________]

7. HIPAA REQUIRED STATEMENTS

7.1 Expiration. This Authorization expires on [__/__/____], or upon the following event: [________________________________]. If no date or event is specified, this Authorization expires upon final resolution of the Patient's personal-injury claim or three (3) years from the date of signature, whichever occurs first.

7.2 Right to Revoke. I understand that I may revoke this Authorization at any time by delivering written notice to the provider/custodian identified in Section 2. Revocation will not apply to information already released in reliance on this Authorization before the provider receives my written revocation. (45 C.F.R. § 164.508(c)(2)(i).)

7.3 No Conditioning of Treatment. I understand that the provider may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

7.4 Redisclosure Notice. I understand that information disclosed under this Authorization may be redisclosed by the Recipient and may then no longer be protected by HIPAA. (Special-category records under Section 5 remain subject to the redisclosure prohibitions of 42 C.F.R. Part 2 and applicable North Carolina law.)

7.5 Right to a Copy. I understand that I am entitled to a copy of this signed Authorization.

7.6 Voluntary. I understand that signing this Authorization is voluntary.

8. NORTH CAROLINA COPY-FEE AND RESPONSE-TIME NOTE

Under N.C. Gen. Stat. § 90-411, a health-care provider may charge a reasonable fee for searching, handling, copying, and mailing medical records to the patient or the patient's designated representative. The maximum fee per request is:

• 75¢ per page for the first 25 pages;
• 50¢ per page for pages 26 through 100; and
• 25¢ per page for each page over 100;
• with a minimum fee of up to $10.00 (inclusive of copying costs).

A reasonable professional fee for a physician's narrative summary is not limited by the per-page caps. Charges for records related to workers' compensation claims under Article 1 of Chapter 97 are governed by the North Carolina Industrial Commission schedule (N.C. Gen. Stat. § 97-26.1). Section 90-411 does not apply to DHHS Disability Determination Services requests for Social Security / SSI disability.

Under the HIPAA right of access (45 C.F.R. § 164.524), a covered entity must generally act on a request within 30 days (with one 30-day extension on notice).

9. SIGNATURE

Personal Representative (if Patient is a minor, incapacitated, or deceased)

Notary (optional)

State of North Carolina, County of [________________________].

Subscribed and sworn to before me on [__/__/____] by [________________________________].

Sources and References

• HIPAA authorization core elements — 45 C.F.R. § 164.508: https://www.law.cornell.edu/cfr/text/45/164.508
• HIPAA right of access — 45 C.F.R. § 164.524: https://www.law.cornell.edu/cfr/text/45/164.524
• Substance use disorder records — 42 C.F.R. Part 2: https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2
• N.C. Gen. Stat. § 90-411 (record copy fee): https://www.ncleg.net/enactedlegislation/statutes/html/bysection/chapter_90/gs_90-411.html
• N.C. Gen. Stat. §§ 122C-52 through 122C-56 (mental health confidentiality): https://www.ncleg.gov/enactedlegislation/statutes/html/byarticle/chapter_122c/article_3.html