NOTE: To release/request information from multiple agencies/organizations, we will need multiple forms filled out. One for each agency/organization.  

Youth/Child Legal Name:   

Youth/Child Preferred Name:  

Date of Birth:       Phone Number:  

 

I authorize: Oregon Community Programs AND  

To REQUEST health information for the above-named individual for the purposes described below.

To DISCLOSE health information for the above-named individual for the purposes described below.

Purposes for which information is being Requested or Disclosed:
Check all that apply:

Types of information being Requested or Disclosed:
Check all that apply:

 

 

Notices:

1. I understand that, if the recipient of the information disclosed under this authorization is not a health plan or provider covered by federal or state privacy laws, the information may be re-disclosed by the recipient and no longer protected by those laws. If the information being disclosed under the authorization includes HIV/AIDS, sexually transmitted infections, mental health, genetic testing, and alcohol/drug abuse diagnosis, treatment, or referral information, Federal law and regulation including 42 CFR Part 2 and 45 CFR Parts 160 and 164 or state law may prevent the recipient from re-disclosing this info.
2. I may refuse to sign this authorization. My refusal will not adversely affect my ability to receive treatment, to enroll in a health plan, to be eligible for benefits, or to obtain payment for services unless this authorization is sought for purposes of research-related treatment, to determine my eligibility or enrollment in a plan, for underwriting or risk determinations or if the services related to the information to be disclosed are performed solely for the purpose of providing that information to someone else.
3. I may revoke this authorization at any time by notifying the Health Information Management/Medical records Department of the above named entity on its designated form. However, any such revocation will not apply to any activity undertaken based on this authorization. Oregon Community Program’s Notice of Privacy Practices also describes how to revoke this authorization.
4. I received a copy of this authorization. I may inspect or request copies of information disclosed by this authorization. Including but not limited to phone, fax, email, and electronic transmission.

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Release of Information Begin Date:

- OR -

If choosing custom start date, you must fill in a date below. Failure to do so will void this authorization. 

Unless revoked, this authorization is valid for 30 days after completion of treatment, unless otherwise indicated:

If you do not wish for this authorization to end 30 days after completion of treatment, please indicate a different date here:

 

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 I have read this authorization and understand it.