AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION ALL SECTIONS OF THIS FORM MUST BE COMPLETED OR THE AUTHORIZATION WILL NOT BE ACCEPTED.

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 will mean you will not receive health services is if the health services are solely for the purpose of providing health information to someone else, and the authorization is necessary to make that disclosure. Your refusal to sign this authorization does not adversely affect your enrollment in a health plan or eligibility for health benefits, unless the authorized information is necessary to determine if you are eligible to enroll in the health plan. 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. Any uses or disclosures already made with your permission cannot be undone. To revoke this authorization, please send a written statement to OHSU Health Services, PO Box 925. Hillsboro OR. 97239-3098 and state that you are revoking this authorization.

I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS information, mental health information, drug/alcohol diagnosis, treatment or referral information and generic testing information.

I have read this authorization and I understand it.

This authorization expires one year from the date of signing unless revoked or otherwise specified below:

MULTIPARTY CONSENT FORM FOR THE RELEASE OF CONFIDENTIAL INFORMATION

2. Oregon Health & Science University

3. Health Share of Oregon 4. Providence Center for Outcomes Research and Evaluation (CORE)

the following information: my referral from a substance use disorder treatment program

The purpose of the disclosure authorized herein is to: Assist in: 1 Determining my eligibility for transitional housing benefits for Health Share members.

2 3 Evaluating the effectiveness of the housing benefit program. 4 Improving the quality of the housing benefit program.

Administering the housing benefit.

I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time, or partially revoke the consent for any of the parties above, except to the extent that action has been taken in reliance on it. and that in any event this consent expires automatically as follows: one year from the date of signature below or upon discharge from the housing benefit program.

Notice to accompany release of confidential information consent form. Each disclosure made with the patient's written consent must be accompanied by the following written statement: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2 The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

You can get this letter in other languages, large print, Braille or a format you prefer. You can also ask for an interpreter. This help is free. Call 888-519-3845 or TTY 711. We accept relay calls. You can get help from a certified and qualified health care interpreter.

Release of Information v-061923 OHP Approval-22-3523