RELEASE OF INFORMATION

AUTHORIZATION TO USE AND/OR DISCLOSE PROTECTED HEALTH INFORMATION

The information used or disclosed in this authorization may be subject to redisclosure and may no longer be protected under federal law. Refusal to sign this authorization will not affect the patient’s ability to obtain health care services or reimbursement for services unless authorization is required to bill the patient’s insurance company. Patient Info

Patient Last Name

Patient First Name

Middle Name

Nickname/Maiden Name

Birth Date

Telephone:

Okay to leave detailed message?

Yes No

Patient’s Mailing Address

Healthcare Provider to Release Information:

Name

Address

City

State

Zip

Phone

Fax

Person or Agency to Receive Information:

Name

Address

City

State

Zip

Phone

Fax

Purpose of release:

If such information exists, I authorize the disclosure of

the entire medical record or the following specific documents, dates of service, and/or information about the following injury/illness/disease:

The following items must be initialed to be released:

HIV-positive test results and HIV diagnosis

Mental health information and/or records (Oregon only)

Genetic testing information and/or records (Oregon only)

Other sexually transmitted diseases (Washington only)

Drug/alcohol diagnosis, treatment or referral information. Per Federal regulations, describe how much and what kind of information is to be disclosed:

Federal or state law may restrict redisclosure of HIV-positive test results and HIV diagnosis, other sexually transmitted disease information, specially protected mental health information, genetic testing information, and drug/alcohol diagnosis treatment or referral information. The person or entity I am authorizing to use and/or disclose the information may receive compensation for doing so. The only circumstance when refusal to sign means the patient will not receive health care 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. My refusal to sign this authorization will not adversely affect my enrollment in a health plan or eligibility for health benefits unless the authorized information is necessary to determine if I am eligible to enroll in the health plan.

I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance upon this authorization. If I revoke my authorization, the information described above may no longer be used or disclosed for the purpose described in this authorization. Unless revoked earlier, this authorization will expire on the earlier of 1 year from the date of signing or on

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

Signature of Patient or Patient’s Legal Representative

Date

Your information will be encrypted.