Website Authorization to Disclose Protected Health Information

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PATIENT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
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:*

One Community HealthOther
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:*

SelfOther
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
Method / Format

How and when do you want the information? (NOTE: Most requests are processed within 30 days)
Choose one:*

Secure Email LinkMyChartFaxMailPick-Up
Urgent Request: Records Needed By:

MonthDayYear
Date
Purpose*

Care ContinuityTransfer of CareWorker's CompensationLegal/AttorneyInsurancePersonal CopyOther
Information to be Disclosed:

(Unless otherwise indicated, records from the past 12 months will be released)
Date(s) of Service From:

MonthDayYear
Date
Date(s) of Service To:

MonthDayYear
Date
Information to be disclosed*

Well Child ChecksHistory & Physical ExamMedication ListImmunization/Allergy RecordLaboratory ReportsVisit NotesDental ImagingAll Clinical RecordsBilling RecordsAll Dental RecordsOther
The following types of records will NOT be disclosed unless checked:

HIV Testing and ResultsSexually-Transmitted DiseasesGenetic RecordsBehavioral/Mental Health RecordsAlcohol, Drug, or Substance Use Records
Information to be disclosed

AssessmentTreatment PlanVisit AttendanceOther
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*

Clear
Date*

MonthDayYear
Date
Print Name*
Relationship to Patient
Should be Empty:

PATIENT INFORMATION

Method / Format

Information to be Disclosed: