RALEIGH, NORTH CAROLINA 27695-7304 FAX: (919) 515-6303

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PHI)

I. Patient's Name _____________________________________ DOB_________________________________

ID Number ______________________________________ Phone Number ________________________

Please check one: Current NCSU Student ________________ Dates Enrolled __________________

Former NCSU Student ________________ Dates Enrolled __________________

Post Doc, TA, Ra, Visitor or Other Patient Type _______________________________

II. Please check one and provide the requested information:

_________ I hereby authorize the NCSU Student Health Services and any of its Medical Providers to disclose my Protected Health Information to the following organization(s) and/or person(s):

Name ____________________________________________________________________

Address___________________________________________________________________

Phone Number: ____________________ Fax Number: _________________________

_________ I hereby authorize _________________________________________ to disclose my Protected

(Primary Care Physician or other Health Care Provider)

Health Information to NCSU Student Health Services and any NCSU Student Health Services health care provider.

III. I authorize the following information to be disclosed:

CHECK DATE(S)

ONE

_____ _________ Complete Medical Record, including records from other providers and immunizations

_____ _________ Complete Medical Record while at NC State, not including records from other providers

_____ _________ GYN (Pap, Pelvic, Lab)

_____ _________ Lab

_____ _________ X-ray

_____ _________ Other or Relating to Particular Problem________________________________

IV. Purpose of the Requested Disclosure: Please check one and provide the requested information.

_____ At the request of the patient. _______________

(Patient’s initials)

______ Other ______________________________________________________________________________

(State specific purpose of requested disclosure)

I understand that I have a right to revoke this authorization at any time. My revocation must be in writing in a letter provided to the Director of Student Health Services or other health care provider identified in Section II above, as applicable. I am aware that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my Protected Health Information have acted in reliance upon this authorization. I understand that I do not have to sign this authorization and that NCSU Student Health Services may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I further understand that if the persons(s) or organization(s) authorized to receive the information is not a health plan or health care provider, the released information may be re-disclosed and would no longer be protected by federal privacy regulations.

I agree that a copy of this release or fax of this release shall be as valid as this original release. If I authorize NC State to fax the information, I realize there are inherent risks in faxing Protected Health Information. I understand a fee will be charged to cover the costs of copying, including the cost of supplies and labor of copying and mailing Protected Health Information released to anyone other than another health care provider. I understand I will get a copy of this form after I sign it.

This authorization expires upon______________________________________

_________________________________________________________ ________________________

Signature of Patient or Patient’s Representative Date

_______________________________________________________________ __________________________

Printed Name of Patient’s Representative Relationship to patient