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  • Authorization to Release/Obtain Information

    Authorization to Release/Obtain Information

    (Dental Only)
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  • I authorize Rogue Community Health to release my health information TO the following person or organization:

  • I authorize the release of my health information FROM the following person or organization to Rogue Community Health:
     
     

  • Information Requested (please initial)
    Dental Radiographs 

  • FROM:   Pick a Date   TO:   Pick a Date   

  • I UNDERSTAND THAT federal law restricts the re-disclosure of the following sensitive information by the receiving entity. Therefore, I understand and agree that my initials next to each type of information will allow that information to be disclosed/obtained.

  • By initialing next to each section, I give my permission for the information to be shared. 
    Mental Health Diagnosis/Treatment     
    HIV/AIDS Test Results/Treatment   
    Drug and Alcohol Diagnosis/Treatment     
    Genetic Testing      

  • 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:

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  • 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 health and protection of a student’s wellbeing 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.

  • Clear
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  • If the patient is unable to sign, or a minor under age 15, or is the ward of a guardian:

  • Clear
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  • Should be Empty: