Oregon Community Programs

Release of Information


Client’s Name:  

Date of Birth:       Phone Number:  

 

I authorize:

Oregon Community Programs
AND
Agency/Organization Name:  

 

To request and 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.

 

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

 

 

 

(Phone Number)

Leave this empty:

Oregon Community Programs https://www.oregoncommunityprograms.org
Signature Certificate
Document name: Release of Information
Unique Document ID: db21829a86820786b337488b15fb8409013bc2e6
Timestamp Audit
March 22, 2020 10:24 am PDTRelease of Information Uploaded by Mindi Brock - mindib@oregoncp.org IP 10.0.1.85
March 25, 2020 5:01 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 25, 2020 5:07 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:20 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:38 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 3:38 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85