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HIPPA Form
  Patient
  Last Name
First Name
Date Of Birth (mm dd yyyy)
  
Dr. Walton K. Joyner and/or his staff is authorized to release protected health information about the above named patient to the entities named below.
Entity to Receive Information (Initial by each that is subject to this authorization)
Leave information in my personal voice mail /or answering machine  
Give information to the following person(s):    
    Last Name
1.
2.
3.
First Name


Description of information to be released (Initial by each that is subject to this authorization)

Financial information
Medical information
Prescriptions, samples, contact lens
Other Information as Described:
The above mentioned person(s) will be required to provide photo ID when picking up requested items.

Rights of the Patient

I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to revoke this authorization at any time in writing, and that I have the right to inspect or copy the protected health information to be disclosed as described in this document by sending written notification to:
Walton K. Joyner, Jr., M.D., P.A.
ATTN: Privacy Officer
3900 Browning Place, Suite 200
Raleigh, NC 27609


I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward.

I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing this authorization.

This authorization shall be in force and effect until revoked by the patient or representative signing the authorization
_______________________________________________
Signature of Patient or Personal Representative
  
Date (mm dd yyyy)


Description of Personal Representative's Authority (Attach Necessary Documentation)