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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). including, and not limited to: -- Psychological, psychiatric or other mental impairment(s) (excludes "psychotherapy notes" as defined in 45 CFR ).

States, and some individual sources of information, require that the authorization specifically name the source that you authorize to release personal information. In those cases, we may ask you to sign one authorization for each source and we may contact you again if we need you to sign more authorizations.

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Transcription of AUTHORIZATION TO DISCLOSE INFORMATION

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resulting from the abuse or neglect of a child(ren). • A request from an out-of-state DSS (public child welfare agency) with a juvenile court case (including permanency planning or termination of parental rights (TPR)) resulting from the abuse or neglect of a child(ren).

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sources with information about you to release that information if you sign a single authorization to release all your information from all possible sources. We will make copies of it for each source. A few States, and some individual sources of information, require that the authorization specifically name the source that you authorize to

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