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The medical record information release (HIPAA) form allows a patient to give authorization to a 3rd party and access their health records. The release also allows the added option for healthcare providers to share information.You can submit a request via our MyAtriumHealth Patient Portal or you can submit a completed Authorization for. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. Please complete all parts of the form to include signature, date, and time. Fill out the form completely. Authorization to Release Health Information. To revoke authorization, send a written request to the address noted below. University of North Carolina Hospitals Chapel Hill, NC 27514. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION FOR CRIMINAL CASES – state COURT.