Authorization to Use / Disclose Health Information (DLM)
Please correct the errors described below.
(Name of physician/physician group)
to use and disclose a copy of the specific health and medical information described below regarding:
(Describe information to be used/disclosed)
to: Dr. Debbie L. Miller, MD 2565 NW Lovejoy, Ste. 100 Portland, OR 97210 ph: 503-279-9700, fx: 503-279-8114
(Describe each purpose of disclosure or state “at the request of the individual” if this authorization is initiated by the individual and the individual does not, or elects not to, provide a statement of purpose.)
Your health care and payment for that health care cannot be conditioned upon receipt of this signed Authorization unless your health care or treatment is for the purpose of:
Creating health information about you to be disclosed to a third party; or
For the purpose of research.
You have the right to revoke this Authorization at any time, provided that you do so in writing. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission. To revoke this Authorization, please send a written statement to: Patient Privacy Manager at Dr. Debbie Miller’s office (2565 NW Lovejoy, Ste.100 Portland, OR 97210) that identifies the date you signed this Authorization, the recipient of the information identified in this Authorization, and state that you are revoking this Authorization.
180 days from the date of signing, or the end of the period reasonably needed to complete the disclosure for the above-described purpose.
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