Authorization to Release/Obtain Information

Authorization to Release/Obtain Information
Patients Name*
First & Last Name
Date of Birth:*

MonthDayYear
Date
I authorize Rogue Community Health to release my health information to the following person or organization:
Name
Address

Street Address

CityState / Province

Postal / Zip Code
Phone Number
Fax
OR

I authorize release of my health information from the following person or organization to Rogue Community Health:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Fax
For the following purpose(s):*

Continuity of CarePersonal UseInsuranceLegalTransfer CareOther
Information Requested (please initial all that apply):
Complete Medical Record initial
Medical Progress Notes initial
Dental Radiographs  initial
Complete Dental Record   initial
History & Physical (SBHC)   initial
Laboratory Reports   initial
Imaging Records  initial
Medication Records initial
Other:  initial   Describe
Time Period

Most Recent 2 YearsSpecific Time Frame
Specific Time Frame
FROM: Date TO: Date
I UNDERSTAND THAT if the requested information includes any of the sensitive information listed below, additional federal or state laws may apply. I attest that this request will not be used for a prohibited purpose*.

By initialing next to each section, I give my permission for the information to be shared.
Mental Health Diagnosis/Treatment   Initials
HIV/AIDS Test Results/Treatment   Initials
Reproductive Care/Treatment   Initials
Drug and Alcohol Diagnosis/Treatment    Initials
*Prohibited Purpose: using the information received to investigate into or impose liability on any person for merely seeking, obtaining, providing, or facilitating lawful reproductive healthcare; and/or to identify an individual or provider to initiate an investigation against the individual or provider in connection with seeking, obtaining, providing, or facilitating lawful reproductive healthcare.

I UNDERSTAND THAT

If we are requesting this authorization from you:

1. We cannot restrict our services or treatment to you on receipt of this signed authorization.

2. You may inspect a copy of the protected health information to be used or disclosed.

3. You may refuse to sign this authorization; and

4. We must provide you with a copy of the signed authorization if requested.

You have the right to revoke this authorization at any time, in writing to the Compliance Department at compliance@roguech.org except to the extent that we have already used or disclosed the information from the use of this original authorization.

This authorization shall expire one (1) year after the date signed unless a different expiration date is written here:
Expiration date: *

MonthDayYear
Date
If I revoke my authorization, the information described above may no longer be used or disclosed for purposes described in this written authorization. The only exception is when a covered entity has acted in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage. (45 CFR§164.508 (c)(2)(ii))

I am not required to sign this authorization. Refusal to sign the authorization will not adversely affect my ability to receive health care services or reimbursement for services. The only circumstances when refusal to sign means I will not receive health services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure. (45 CFR§164.508 (c)(2)(ii)) I have a right to request, in writing, a list of protected health information disclosures as permitted under federal or state law.

At RCH’s school-based health centers, protected information will be used or disclosed only when it is necessary to satisfy a particular purpose or carry out a function related to the health and protection of a student’s well-being and ability to learn and succeed.

I have reviewed and I understand this authorization. I also understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law. I hereby authorize the release of information between Rogue Community Health and the authorized organization/person listed above.
Signature*

Clear
Date*

MonthDayYear
Date
If the patient is unable to sign, or a minor under age 15, or is the ward of a guardian:
Representative’s Signature:

Clear
Representative’s Printed Name:

First NameLast Name
Relationship of representative to patient:
Preferred method of receipt:*

MailFaxPick-up in clinic
Should be Empty: