DHHS 4056-Patient Authorization (English-Spanish) - publichealth nc-2025

1. Click ‘Get Form’ to open the DHHS 4056 form in the editor.
2. Begin by entering the patient's last name and first name at the top of the form. Ensure accuracy as this information is crucial for identification.
3. Fill in the patient’s Social Security Number and Date of Birth in the designated fields. This information helps verify the patient's identity.
4. In section [1], specify who is authorized to use or disclose the health information. This could be a specific person or a class of persons, such as healthcare staff.
5. For section [2], indicate to whom the information will be disclosed. Be clear about whether it’s an individual or an organization.
6. Describe the purpose of disclosure in section [3]. This could include reasons like treatment, research, or other specified needs.
7. Complete sections [4] through [7] by providing necessary details about revocation rights, expiration date of authorization, and representative authority if applicable.
8. Finally, ensure that either the patient or their authorized representative signs and dates the form at the bottom before submission.

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