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One Community Health (OCH) will only release Protected Health Information (PHI) as permitted by patient confidentiality laws. OCH reserves the right to use or disclose patient’s PHI without patient’s consent to the extent allowed by applicable law, including but not limited to uses or disclosures identified in OCH’s Notice of Privacy Practices.
Patient Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
I hereby authorize OCH staff to leave voicemail messages at the following phone number(s):
I hereby authorize OCH staff to discuss my PHI with the following person(s):
Certain information cannot be released without specific authorization as required by state or federal law. By checking the specific boxes below, you authorize the disclosure of the following protected information with the listed family or friends:
Mental health diagnoses, prognosis, and treatment
Substance use diagnosis, prognosis, and treatment
Pregnancy information
HIV/AIDS Virus
Sexually Transmitted Diseases
I understand that this authorization is valid as long as I am a patient of OCH, or I revoke my authorization.
I understand that I may revoke this authorization in writing at any time but that revocation of this authorization will not apply to information already released.
This authorization allows for verbal communication (both in person and on the telephone) between OCH and the designated person(s) on this form. It does not allow for copies of medical records to be released.
This form is not valid unless signed and dated.
Signature of Patient/Representative
*
Date
*
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Month
-
Day
Year
Date
Name of Representative
First Name
Last Name
Relationship of Personal Representative
Submit
Should be Empty: