Triad Primary Care Greensboro, NC Form

HIPAA Privacy Authorization Form

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

First Name:

Last Name:

Email Address:

Mobile phone number:

Date of Birth:

1. Authorization

Healthcare provider:

I authorize (above healthcare provider) to use and disclose the protected health information described below to (individual seeking the information)

2. Effective Period

a. This authorization for release of information covers the period of healthcare from:

a. This authorization for release of information covers the period of healthcare from: To

**OR**

b. all past, present, and future periods.

**3. Extent of Authorization**

a. I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).

**OR**

b. I authorize the release of my complete health record with the exception of the following information:
Mental health records
Communicable diseases (including HIV and AIDS)
Alcohol/drug abuse treatment
Other

If other, please specify

HIPAA Privacy Authorization Form

Patient Information

**1. Authorization**

**2. Effective Period**

1. Authorization

2. Effective Period