AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
ALL SECTIONS OF THIS FORM MUST BE COMPLETED OR THE AUTHORIZATION WILL NOT BE ACCEPTED.
I authorize: __________________________________________________________________________________________________
(Name of person / entity/ facility disclosing information)
_______________________________________________ ______________________ ______________ ____________
(Address of person / entity) |
(City) |
(State) |
(Zip Code) |
to use and disclose an electronic copy of the specific health information described below; unless you check here ¸ for a paper copy. This release is regarding:
__________________________________________________________________________________________________________________
(Name of individual)
(see back side for definitions) _______ Physician reports _______ X-rays (please see the back side of this
form for complete instructions) _______ Labs _______ ED ______ Billing ______ Radiology Report
Other, specify
______ If outpatient practice/clinic records are needed, please specify the practice(s)/clinic(s) (see back side for
practice/clinic list) ______________________________________________________________________________________
to: __________________________________________________________________________________________________________
(Name of recipient)
_____________________________________________________ _______________________ ______________ ____________
(Address of recipient)(City)(State)(Zip Code)
for the purpose of: (Describe each purpose of disclosure) _______ Continued Care _______ Legal _______ Disability
_______ School Entry _______ Other, specify _______________________________________________________________
If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed only if I place my initials in the applicable space next to the type of information.
______ |
HIV/AIDS information |
|
|
Genetic testing information |
______ |
Mental health information |
|
|
Drug/alcohol diagnosis, treatment, or referral information |
You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign will mean you will not receive health services is if the health services are solely for the purpose of providing health information to someone else, and the authorization is necessary to make that disclosure. Your refusal to sign this authorization does not adversely affect your enrollment in a health plan or eligibility for health benefits, unless the authorized information is necessary to determine if you are eligible to enroll in the health plan.
You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any uses or disclosures already made with your permission cannot be undone.
To revoke this authorization, please send a written statement to Medical Correspondence, Health Information Services, OP17A, OHSU 3181 SW Sam Jackson Park Rd. Portland, OR 97239-3098, and state that you are revoking this authorization
I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict re- disclosure of HIV/AIDS information, mental health information, genetic information and drug/alcohol diagnosis, treatment or referral information.
I have read this authorization and I understand it.
This authorization expires one year from the date of signing unless revoked or otherwise specified below:
(enter alternative expiration date or event) ________________________________________
By:______________________________________________________________________________Date:___________________
(Signature of individual or personal representative)
Description of personal representative’s authority:_________________________________________________________________
