SBHC Authorization to Disclose Information

SBHC Authorization to Disclose Information
If the student is 13 years old and under:
This ROI is required for the student to participate in the program and must be signed by the parent or guardian for students 13 years old and under.

Once the form is complete, the SBHC team will schedule a visit, so the parent/ guardian and student can meet the Behavioral Health Consultant (BHC) together. This initial visit can be in person at the School Based Health Center (SBHC) or virtual and is to ensure everyone understands the student’s needs and next steps for care.

If the student is 14 years or older:
The student can consent for their own behavioral healthcare and can start by completing the Release of Information (ROI), which is a consent for the school to help coordinate services.
Patient Information*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Disclose Records from:*

One Community HealthOther
One Community Health

849 Pacific Ave, Hood River, OR 97031

Ph. 541-386-6380

Fax. 541-256-4208
Disclose records to: *
Hood River Middle School Attendance and Counseling Office

1602 May Street, Hood River, OR 97031

Phone: 541-386-2114
Hood River Valley High School

1220 Indian Creek Rd, Hood River, OR 97031

541-386-2770
Wy'east Middle School

3000 Wy'east Rd, Hood River, OR 97031

541-354-1548
Dufur School Attendence and Counseling Office

802 NE 5th Street, Dufur, OR 97021

541-467-2509
South Wasco County High School Atendance and Counseling Office

699 4th Street, Maupin, OR 97037

541-395-2225
The Dalles Middle School Attendence and Counseling Office

1100 East 12th Street, The Dalles, OR 97058

541-506-3380
The Dalles High School Attendance and Counseling Office

220 E 10th Street, The Dalles, OR 97058

541-506-3400
Method/Format- How and when do you want the information? (NOTE: Most requests are processed within 30 days)*
Urgent Request: Records Needed By:

MonthDayYear
Date
Purpose*

Care ContinuityTransfer of CareWorker's CompensationLegal/AttorneyInsurancePersonal Copy

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. This authorization will expire on the following date or event (if none specified, in 12 months) unless you revoke/cancel this Authorization sooner.

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:
This Authorization will expire on the following date or event: (if none specified, in 12 months), unless you revoke/ cancel this Authorization sooner.

MonthDayYear
Date
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