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AUTHORIZATION TO DISCLOSE INFORMATION

DHB- 5028 (02/2020). WHOSE Records to be Disclosed: NORTH CAROLINA First Middle Last NAME: DIVISION OF health BENEFITS. Birthday mm/dd/yy SSN: -------------------------- COUNTY. DEPARTMENT OF SOCIAL. ADDRESS: SERVICES. AUTHORIZATION TO DISCLOSE INFORMATION . I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange): OF WHAT: All my medical records; also education records and other INFORMATION related to my ability to perform tasks. This includes specific permission to release: 1. All records and other INFORMATION regarding my treatment, hospitalization, and outpatient care for my impairment(s).

disclosed to SSA/DDS or DSS, it is no longer protected by the health information privacy provisions of 45 CFR part 164 (mandated by the Health Insurance Portability and Accountability Act (HIPAA). SSA/DDS and DSS retain personal information in strict adherence to the retention schedules established and maintained in conjunction with the National

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