HIPAA and Release Forms ** HIPAA & Release Forms **Note: This contains HIPAA & Release information ONLY. It does NOT contain all the forms. Only use this page if specifically requested by your provider.PROVIDER INFORMATIONPlease select your HFM location:*ClaytonFour OaksRiverwoodSmithfieldWhich Clayton Provider do you see?*Dr. WilliamsDr. HarrisDr. KahnDr. McGillDr. SelakDr. NorrisMegan Wester, PABrittany McCall, FNP-CWhich Four Oaks Provider do you see?*Dr. WatsonCourtney Powell, PA-CWhich Riverwood Provider do you see?*Dr. HebdaJessica Heath, MPAS, PA-CWhich Smithfield Provider do you see?*Dr. PittardDr. LivermanDr. DavisDr. RyanJenah Manzano, PA-CPATIENT INFORMATIONLegal Name (First, Middle, Last):Suffix:SSN#:Date of Birth:Home Address:Home City State Zip:Mailing Address:Mailing City State Zip:Home Phone:Work Phone:Cell Phone:Email Address :Note: Your email address is part of your protected health record and will not be sold or spammed** PRIVACY INFORMATION (HIPAA) **I authorize Horizon Family Medicine to contact me and/or to leave telephone messages in the following ways: Home Phone Work Phone Cell Phone Email I authorize Horizon Family Medicine to release my medical information to the named persons listed below: Spouse/Parents/Children (specify below) Other (specify below) Names of Persons Authorized to Receive my Medical Information:READ & SIGN BELOWI certify that the information provided is correct and complete to the best of my knowledge.Date:Signature of Patient (or Legal Guardian)** AUTHORIZATION FOR RELEASE **Date of Birth:Patient Name:Other Name:Street:City State Zip:Phone:Cell:I authorize the release of medical information as indicated below: I would like to pick up my records, please call me at the number above. I would like the records mailed (please indicate the address above). What to Release: Please choose the records you would like released: Outpatient note(s) X-Ray report(s)/film(s) Laboratory reports(s) Immunization record Pathology reports(s) ALL Medical records Other, please specify Other what to release:NOTE: The records listed below have special protection by law. I authorize the release of information pertaining to:The diagnosis or treatment of AIDS, including results of HIV tests:YesNo/NAThe diagnosis or treatment of drug and/or alcohol abuse:YesNo/NAThe treatment and/or consultation for mental health or psychiatric disorders:YesNo/NAPurpose of the release: Please indicate the reason for this release:: Transfer care For use in a lawsuit Follow-up related to an injury Personal use To obtain disability Worker’s compensation Armed Forces requirement For another doctor Other, please specify Other purpose of release:Expiration date: This authorization will expire in sixty days unless otherwise indicated below: Please change the expiration date, enter days below Number of days for expiration date to last:READ & SIGN BELOWI understand this Authorization can be revoked at any time according to Horizon Family Medicine’s privacy practices. This request must be made in writing. Once these records are released, the information is not protected by Horizon Family Medicine and may potentially be re-disclosed by the party who received these records. Horizon Family Medicine, its employees and officers, and attending physicians are released from legal responsibility or liability for release of the above information to the extent indicated and authorized. I have read and understand this information. I have received a copy of this form, and I am the patient or am authorized to act on behalf of the patient to sign this document verifying authorization for the use or disclosure of the protected health information under the above stated terms.Date of patient signature:Signature of Patient:Date of Legal Representative Signature AND Relationship to Patient:Signature of Legal Representative:CAPTCHANameThis field is for validation purposes and should be left unchanged.