Form DHHS-DAAS-9112 Resident Authorization Form - North Carolina

Form DHHS-DAAS-9112 Resident Authorization Form - North Carolina

What Is Form DHHS-DAAS-9112?

This is a legal form that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is the DHHS-DAAS-9112 Resident Authorization Form?
A: The DHHS-DAAS-9112 Resident Authorization Form is a document used in North Carolina to authorize the disclosure of protected health information of a resident in a long-term care facility.

Q: Who needs to complete the DHHS-DAAS-9112 Resident Authorization Form?
A: The form should be completed by the resident or their legal representative.

Q: What is the purpose of the DHHS-DAAS-9112 Resident Authorization Form?
A: The form allows the long-term care facility to disclose the resident's protected health information to third parties, such as family members or healthcare providers, with the resident's consent.

Q: Is the DHHS-DAAS-9112 Resident Authorization Form mandatory?
A: No, completion of the form is voluntary, and the resident has the right to revoke their authorization at any time.

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Form Details:

  • Released on March 1, 2006;
  • The latest edition provided by the North Carolina Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHHS-DAAS-9112 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

Download Form DHHS-DAAS-9112 Resident Authorization Form - North Carolina

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  • Form DHHS-DAAS-9112 Resident Authorization Form - North Carolina, Page 1
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