Carolinas HealthCare System There may be a charge for record copies.

Authorization for Release of Health Information

I hereby authorize the use or disclisure of my identifiable health information as described below. : understand ha’ 1 n a rgaruzat r, eutnorcze t cr:eive

tue ,r.f rrnat:cn cc not ar insurance rrpacr or he:n care prvcer, tf rdI aced rma’ori tray no or gr a o rote te fe “ral fcvacy regu1a’ rs

PURPOSE OF RELEASE:

faciiy ec’ic :r,a vidual Iiti a,ow is authortd : lease ‘he eq s’u dee inforrn’ur

Facility. Practice Name.

Facility•’Practice Address Fax

Telephone k: —________

CHECK THE SPECIHC INFORMATION TO BE RELEASED:

- Frorrr M!t’ID’Y’’ To tMM D TY ——

All Records & Details I] u-g- nrnery J ha :docv Papc: :c 3 Prg:

J Aop :rnen’ Iurniat:n J um—!gen- itOo c is I teuiceuori corus J t’’ ‘OC :vui —

J P:tling lnforrrstc:on f-’orv & Ph’ s:s1 Cffice/Ci:nic o’es P i”lcy/irrgrcg Pepnrts —

_______ _______

J nchscn’r. Peoor’ J ln.crn-2a’cn Rerords J Cperauve hecc:t Ii Tet Results

_____________

u2an’scrcco tst the a”J r:t: ;u:ny sneocral r,000 mac’ cirdude a-uccnaoco alecu:e cc r cf drug cc aluze, aidrle cra cc

.irn,rsirzeocc, cexcay ncn:nedd,seeoe, arc so- deltcsency gvcsdrcze ADS;, AIS ce/c ,rdeac ;A2I thcnananc:eocy torus

NAME OF PATIENT WHOSE INFORMATION IS TO BE RELEASED:

Patient Name:

_________________________________ ____________________________________ _____________________________________________

Fira die/ivts5en Last

Patient Address:

_____________________

Surat Adthe/PO Su, cay, 5ta, Zipi

Social Security#:

__________________________

Date of Birth:

__________________

Medical Record/Chart

_____________________

Please provide phone numbers where you are authorizing Cl-IS to leave patient information as described above:

Home:

___________________________________

Work: Cell:

I 1 This informatcon my be released to and used by ‘he following individuals/organizations A separate authorization must be

completed if the informs tion being released or the purpose differs between the indiv:duals/organzstions listed below

Name Address Telephone/Fax Relationship

PATIENTS RIGHTS AND SIGNATURE:• I understand that I have a right to revoke this authorization at any time by notifying the Medical Record Department of the above named organization

ifl mriting unders’and that rocation wi’l nnt apply to information that has alreadybeen released ,n response to this authorization I understand that

revocation will not apply to rn,’ ,nsuran e company when the law prov des my :nsurerwth the rIght to rontest a claim under my policy,

• : unders’ar.d :hac a:horiz:np the d:sicsure of cfl:s prrja’e health :ncorrn3tcon 0 voiuntacr’ and I can refuse tj s:mt thu authorizatron

c.er ‘—“a “a, cC S “v “ 5 “ ‘tr’ “ro e. .s 1” cci oe d”-’S e a i Pn

• no 3utnr:zat:c:. 5cc.. ep:re wur: tflc :n:o:iua:,cn :rom tue event’purnrsc ru1ea acove : ce.easea ‘a racip:ent named 0 mis

If the patIent is a minor or is cn.’alIy unafie’o sign, an authorized representative may sjgn th,s authorization.

PRINT NAME (Patient’Authorized Representative>: —

SIGNATL’RE:

________________________________

DATE:

______

if sthor:zed eprserave, pleoCe :,iate r a’u—uch:p ‘a pa’ien U oou-e U Parent U uerd:au U Eecuur P’’e U Rower

•i I’LIJ l1t11k III f14 flarte note, if the :rforma’:on relaung ‘a the ‘reatment of pregnancy, drug and/or alcolt,. ebuse, vsnereal dseae,

SAME OF MINOR: SIGNAI[RE OF MINOR: DATE:

_________________________________________

it ‘he rthuestor of petier.’IntCrrr’tIOn is e health are provider wli r,e ha lilt care prov:der rcce,”e any

• f,nsn,,al crr,—er.s,t,’-r, :r. ss-hsug” I r u.ng r ,iscL,rp ‘h” i.aIth :c.forms’.u desribed arrvet U U Na U hI “A

-

U I ien’,fic”ian verified U ny 5Au’Lr z’ n e “'n ‘0 ptien’ Dae of rel’se - — via U Med U fx U T’h r

U A’u’pt”i Pt,ssco :uRum’:- a /‘s-rilro’c ahr’ve U I coolly A:cep’ed - Descnbe psueru ,nf”rrcia:”:, r t c/se ed

One patient per authorization form

RELEASE FROM:

Ca.ruUnas Hea1thD4re Systemljn Paciente Por Formulario de Autorizac iOn Podria Haber un Costo pot Copias de Historialesi

Carolinas HealthCare System - Authorization for Release of Health Information Form

Carolinas HealthCare System — Formulario de Autorizacidn para Dar a Conocer InformaciOn de Salud

Por medlo del presente, autorizo ci usa o Ia revelaciOn de ml informaciOn de salud identitIcabie coma es descrito abajo. Een a 015 orgnzaos autrndaa recair is inibunstnno as toss ctoncaffs da saguro on provsadcr da saind, a nfc ans ariragath padrds yanc ssr protsth pto las reg.iiardsasas ftdsraias de roivandad..

1J OttoPROPOSITO DE LA ENTREGA

ENTRE.GA POR PARTE DE

NOMBRE DEL PACIENTE CUYA INFORMACION SERA ENTREGADAI

Nombre dcl Paciente:

___________________________ __________________________ __________________________________________

Pnznao Seg,mdofDe Soltera ApellidoDirecciOn dcl Paciente:

(DimrciOn de CallefApdo. Postal, Cialad, Estado, Cogo Postal)Nümero de Seguro Social ___________Fecha de Nacimiento: Nslmero de HiatoriaVHc1jaMëdica___________

Por favor, provea los nilmeras tclefOnicos donde usted está antorizando a Cl-IS a dejar Ia informaciOn del paciente descrita arriba:Casa:

___________________________

Trabajo:

___________________________

Celular:

_____________________________

ENTREGARA Esta InformaciOn puede set enticgada a y usath par los sigiientes Individuus/organizacianes. Una autorlzaciOn aparte debe setcompletada si Ia InformaciOn entresda a ci propOs Ito difieren entre los individucis/organizaciones anotados abajo:Nombre DirecciOn Namera Teiefonico/Fax Parentesco/Reiación

DERECHOS YFtRMA DEL PACIENTE• Entiendo que tengo ci derecho de revacar esta autorizaciOn en ciniquier momenta a! notificar par esthto al Departamento de Registros Medicos (“Medical

Record Department’) de Ia organizaclon mencknnda arriba. (Entiendo que Ia revocaciOn nose aplicata a Ia InfortmciOn que ya ha sido entregada enrespuesta a esta autorizaciOn. Entlendo que una revocaciOn no se apilcarti a ml compatifa de seguro cuando Ia Icy Ic otorga ci derecho de impugnar unrecktmo baja mipOlIza)

• Entlendo que autorizar Ia revelaciOn de esta InformaciOn de salad privada es vohmtario y pueda rehinarme a ftrmar esta autorizaciOn.• Entiendo, segiin ci CR5 Anundo de Câno Manejamos Is Privacidad, que puerto solicftar insperdanar a obtener nasa copia de Ia información a ser usada a revelada.• Esta autorizaclOn se vencertl cuanda Ia infarmaciOn dci evento/praposito anotado arrlba es entregada sal destinataria nombrada en este docamento.Si ci paciente es menor de edad a es incapaz clfttlcamente de firmar, on representante autorizada puede firmar esta autorizaciOn.NOMBRE EN LETRA DE IMPRENTA (PacientelRcpresentantaAutorizada):

FIRMA: _________

________________________

FECHA:

______________

Si Ia firma es dat na Repretsentante Autodzacb, par ftvor, indique so prenlesco/reiaci& LI £sposo/a LI PadteiMadre LI Guardian LI Testaenentario LI ApOdeIadO

Si ci soli ilatle (I.’ hi infima iOn es tin prov.’edor de naidid de sa hid. recibira I algnn,i cimpensaciOn Ilnanciera aiambi dcl its a re’. ehicisti di La infrirnil ion descrita aruba? LI Si LI a LI ‘ se

LI ide,itiflcalin verifled LI (.pv of AiithrizaIion p,iven I patient? Date of relate: - - _via LIMail LIFax ,.JOlher

__________

—

LI :\cccpteci Riensed imifnmtton is described abve LI Partially Accepted - Descnbc patient information not released:

__________________________

CHS Employee Name & Title:

_________________________________CR5

Employee Signature:

_________ __________Date _______

PFS L4t5-AR, Gil, CC

LIComunicacion en Coma LICopia del Historial LIRevisidu Legal o del Segure LIScisrotaco da on epresen?ana Autnzado

____________________________

La nstaiaciOncoosultoris/individuo anotado abajo estti autorizado a entregar Ia infornnciOn de salud soiicitada:Nornbre de Ia in.sta!aciOniconsultorio:

____________________________________

Niimero TelefOnico

____________________

DirecciOn de Ia instalaciOniconsultorio:

___________________________________________

TicipfQ de Fax________________________La instaladOn/comuitori&indivithjo anotado arriba esia autorizado a entregur Ia informaciOn de salad par Ia siguiente: fecha(s) del servicio, margen detiempo a eventa(s): Desde:(mes’dfa/ana)_ Hasta:(mes!diaiafia)

MARQUE L.A INFORMACION ESPEC fFICA A SER ENTREGADA LI Ordencs dcl Doctor LI Otros (Par favor, cspecifique)LI To slasHsstohesyDeta1lasJ Resumendel Alta LI RepanesdaLbatsroi’atatoga LI Notas de ProgresoLI informaciOn de Citas LI Hsstonala dslaSaii ds noegoscas LI Registro de Medicamentos LI EtaluidnPrevia PsiquisincaLI InforrnaciOn de Cobros LI I-hstorlal y Examcn Fisico LI Notas dat OflcinalCllnica LI Radlologfa/Reportcs de IntagenesLI Reporte de isa Coasulta LI Registro de Vacunas LI Reporte Operatorlo LI Resultados de Pruebas

____________________

Entimdo sue Ia informacidn s mi historial nadico puede nciusr infmaci relac.ionada a tratansiento di abuso de droga 0 alcohol, anemia di céiulas falcifrnes, inouficimciapsicolagics o psituiStrica, esfmedades por transmisidn sexual, sthdrne de inmunodeficie-scia adquirids (SIDA).. ctonplejo relacionado al SIDA y/n otros virus de lx srrosnodgiciesciahumans lH).

FIRMA DEL MENOR DE EDAD

COMPENSACION FINANCIERA

Par favor, tome nota, ti Ia infornnciOn es relaclonada sal tratamiento de tin embarazo, abti.so de cfroga yb alcohol,cnfermedad vengren, ci trastorno emocional pam na pacierite menor de 18 aficas de ethd, ci paclente debe tambien firmar esta autorizaciOn.NO MERE Dfl. MENOR: FIRMA DEL MENOR:

_______

FEC HA:

______

*

Carolinas Physicians NetworkCarolinas HealthCare System

ACKNOWLEDGEMENT FORM

Medical Records #

Patient’s Name:

__________ _____________

Date of Birth

______/

/______

Day Month Year

We are required by law to provide you with our Notice of Privacy Practices which explainhow we use and disclose your health information. We are also required to obtain yoursignature acknowledging that this notice has been made available to you.

Signature:

_____________________________________________

Date:

__________ _______

(Patient or Authorized Representative)

Relationship to Patient:

__________

Self

________

Spouse

___________

Other

____________

Reason Patient Unable/Unwilling to Sign: -

_________

ACKNOWLEDGEMENT FORMDOCUMENTO DE RECONOCIMIENTO DE CAROLINAS PHYSICANS NETWORK

Numero de Registro Medico

________________

Nombre del Paciente

______ _____________

Fecha de Nacimiento I IDia Mes Ano

La ley nos requiere que nosotros Ic proveamos a usted con nuestro Aviso de Practicas dePrivacidad las cuales explican como podemos usar y divulgar su informacion medica. LaIcy tambien nos requiere que obtengamos su firma, reconociendo que este aviso lo hemoshecho disponible para usted.

Firma:

______ __________

Fec ha:

______ _____ _____ _____

(Paciente a Representante Autorizada)

Relacion al Paciente: Mismo __ Esposa (a) Otro

Razon Por la Cual El Paciente No Puede/No Desea Firmar: —_____

CHr2-2HP

Name (Last, First, Middle) Relationship

Home Phone Number Work Phone Number Cell Phone Number

AUTHORIZATION, ASSIGNMENT OF BENEFITS, AND REFERRAL MEDICAL RELEASE:

I hereby authorize the release of medical information including complete medical records, test results, andbilling information to my insurance company, and to other medical professionals and medical care institutionsthat I may be referred to for treatment. I understand that this information will be used to review, investigate, ormake payment of a claim, and to review records for quality improvement initiatives, audit compliance,utilization management, and compliant resolution. I authorize payment directly to Carolinas PhysiciansNetwork for all medical or surgical benefits otherwise payable to me under terms of my insurance. I understandthat I am financially responsible for all co-payments, co-insurance, deductibles, and non-covered services. Aphotocopy of this authorization shall be considered as effective and as valid as the original.

Signed: _________________________________________________________________ Date _________ / _________ / _________

Office Use Only:General Comment Section:

EMERGENCY CONTACT: (Other than Mother or Father)