ORS 192.566 Authorization Form

ORS 192.566 Authorization Form

A health care provider may use an authorization that contains the following provisions inaccordance with ORS 192.559:
AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
I authorize:
Name of person/entity disclosing information
To use and disclose a copy of the specific health information described below regarding:
Name of Individual
consisting of:
describe information to be used/disclosed
to:
name and address of recipient or recipients
for the purpose of:
(describe each purpose of disclosure or indicate that the disclosure is at the request of the individual
If the information to be disclosed contains any of the types of records or information listed
below, additional laws relating to the use and disclosure of the information may apply. I
understand and agree that this information will be disclosed if I place my initials in the
applicable space next to the type of information.
Type a question

HIV/AIDS InformationMental Health InformationGenetic Testing InformationDrug/Alcohol Diagnosis, Treatment, or Referral Information
I understand that the information used or disclosed pursuant to this authorization may be
subject to redisclosure and no longer be protected under federal law. However, I also
understand that federal or state law may restrict redisclosure of HIV/AIDS information, mental
health information, genetic testing information and drug/alcohol diagnosis, treatment or
referral information.
Provider Information
You do not need to sign this authorization. Refusal to sign the authorization will not adversely
affect your ability to receive health care services or reimbursement for services. The only
circumstance when refusal to sign means you will net 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.

You may revoke this authorization in writing at any time. If you revoke your authorization, the
information described above may no longer be used or disclosed for the purposes described in
this written authorization. The only exception is when a covered entity has taken action in
reliance on the authorization or the authorization was obtained as a condition of obtaining
insurance coverage.
To revoke this authorization, send a written statement to
(Name and address of recipient orrecipients)
Signature
I have read this authorization and I understand it. Unless revoked, this authorization expires:
(insert Applicable Event)
Or Date

MonthDayYear
Date
Signature of Individual or Personal Representative

Clear
Today's Date

MonthDayYear
Date
Description of personal representative’s authority:
Should be Empty:

ORS 192.566 Authorization Form

Provider Information

Signature