Release of Information
Date of Birth: Phone Number:
Oregon Community ProgramsANDAgency/Organization Name:
To request and disclose health information for the above-named individual for the purposes described below.
Authorization to REQUEST Information Authorization to DISCLOSE Information
Purposes for which information is being Requested or Disclosed:
Check all that apply:
Types of information being Requested or Disclosed:
Unless revoked, this authorization is valid for 30 days after completion of treatment, unless otherwise indicated:
Beginning Date: Ending (expiration) Date:
I have read this authorization and understand it.
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Release of Information
Agree & Sign