Release of Records

OKLAHOMA STANDARD AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)

Patient Name

Date of Birth

Medical Record #

Social Security #

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I hereby authorize

Name of Person/Organization Disclosing PH

to release the fo llowing information to

Name and Address of Person/Organization Receiving PHI

Information to be shared:

Psychotherapy Notes (if checking this box, no other boxes may be checked)

Billing Information for

Entire Medical Record

Mental Health Records

Substance Abuse Records

Medical information compiled between

Other

The information may be disclosed for the following purpose(s) only:

Insurance

Continued Treatment

Legal

At my or my representative's request

Other

I understand that by voluntarily signing this authorization:

I authorize the use or disclosure of my PHI as described above for the purpose(s) listed.
I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke this authorization at any time. The revocation must be made in writing to the person/organization disclosing the information and will not affect information that has already been used or disclosed.
I have the right to receive a copy of this authorization.
I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing this authorization will not affect my eligibility for benefits, treatment, enrollment or payment of claims.
My medical information may indicate that I have a communicable and/or non-communicable disease which may include but is not limited to diseases such as hepatitis, syphilis, gonorrhea or HIV or AIDS and/or may indicate that I have or have been treated for psychological or psychiatric conditions or substance abuse.
I understand I may change this authorization at any time by writing to the person/organization disclosing my PHI.
I understand I cannot restrict the information that may have already been shared based on this authorization.
Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by the Privacy Regulation.

Unless revoked or otherwise indicated, this authorization's automatic expiration date will be one year from the date of my signature or upon the occurrence of the following event.

Signature of Patient or Legal Representative

Date

Description of Legal Representative's Authority

Expiration date (if longer than one year from date of signature or no event is indicated)

Your information will be encrypted.