Health Info Disclosure

AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION

5909 S.E. Division St., Portland, OR 97206 Phone (503) 234-1531 Fax (503) 234-2367
Please select a doctor:*

Joan Takacs, D.O.John Takacs, D.O.
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
From Organization (This is who you want your health care records from)
From Organization (This is who you want your health care records from)
Hospital/Facility Name:
Provider Name*

First NameMiddle NameLast Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To Organization (This is who you want to receive your health care records)
To Organization (This is who you want to receive your health care records)
Hospital/Facility Name:
Provider Name*

First NameMiddle NameLast Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To name can not be the same as From name. Please correct the error.
The information will be used on my behalf for the following purpose(s):*

Continuity of CareTransferring PhysicianBillingOther

By initialing the spaces below, I specifically authorize the release of the following information, if such records exist:

	Initials
Medical records and office chart notes for continuity of care
Lab reports / Pathology reports
Diagnostic imaging reports (x-ray, MRI, CT scan, Ultrasound)
Billing statements
Emergency, urgency care records, hospital records
Other
* HIV/AIDS – RELATED RECORDS
* MENTAL HEALTH INFORMATION
* GENETIC TESTING INFORMATION

If other, please specify:
ALL ITEMS THAT HAVE AN ASTERISKS NEXT TO THEM (*) MUST BE INITIALED TO BE INCLUDED WITH OTHER DOCUMENTS.

**DRUG/ALCOHOL DIAGNOSIS, TREATMENT OR REFERRAL INFORMATION, FEDERAL REGULATION, 42 CFR PART 2, REQUIRES A DESCRIPTION OF HOW MUCH AND WHAT KIND OF INFORMATION IS TO BE DISCLOSED.

	Description	Initials
This authorization is limited to the following treatment:
This authorization is limited to the following period:
This authorization is limited to a worker's compensation claim for injuries of (DOI):

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:
1. Creating health information about you to be disclosed to a third party; or
2. 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 Medical Records Department at 5909 S.E. Division ST., Portland, OR 97206, 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”.

This Authorization will expire on the earlier of (fill the date below), 180 days from the date of signing, or the end of the period reasonably needed to complete the disclosure for the above-described purpose. I have reviewed and I understand this Authorization. I 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 also understand the charge is $30.00 for each copy of my records that I request.
This Authorization will expire on the earlier of (fill the date below), 180 days from the date of signing, or the end of the period reasonably needed to complete the disclosure for the above-described purpose. I have reviewed and I understand this Authorization. I 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 also understand the charge is $30.00 for each copy of my records that I request.

MonthDayYear
Date
(Patient or Patient’s representative)*
(Date)

MonthDayYear
Date
Description of Representative’s Authority
Signature*

Clear
Should be Empty:

AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION