Authorization to Disclose Protected Health Information

Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Disclose Records From:

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Fax Number

Area CodePhone Number

Disclose Records To:

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Fax Number

Area CodePhone Number

Email

example@example.com

Choose one:

Urgent Request: Records Needed By:

Date

Purpose

Date(s) of Service From:

Date

Date(s) of Service To:

Date

Information to be disclosed

The following types of records will NOT be disclosed unless checked:

Information to be disclosed

Other

This Authorization will expire on the following date or event: (If none specified, in 12 months)

You are not required to sign this Authorization. The care provided to you by One Community Health will not be affected if you do not sign.
You may revoke/cancel this Authorization at any time by writing to One Community Health’s Privacy Officer at 849 Pacific Ave. Hood River, OR 97031. Revoking/canceling this Authorization will not affect any use or disclosure of your health information that has already taken place.
Once your health information is disclosed, it may no longer be protected by federal and state privacy laws and re-disclosed to others. However, certain types of sensitive information (such as HIV/AIDS information, behavioral health information, genetic testing information and substance use information) may be protected by laws that do not allow re-disclosure.
This Authorization must be signed and dated by the patient or the person authorized by law to serve as the patient’s personal representative. A personal representative who is the patient’s legal guardian or custodian or has health care power of attorney for the patient must provide legal documentation demonstrating his/her authority.
OCH may charge a reasonable cost-based fee for copies of records in compliance with state and federal laws.

I have reviewed and understand this Authorization to Disclose Protected Health Information:

Signature

Date

Print Name

Relationship to Patient

PATIENT INFORMATION

Method / Format

Information to be Disclosed: