Release of Information

Authorization for the Use and Disclosure of Protected Health Information
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Photo Identification*

Cancelof
Clinic/Hospital/Healthcare Provider

Who has the information you want released?
Name of Facility/Person*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Receiving Party

Where do you want the information sent? Who may have the information?
Name of Facility/Person*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Information to be Released
Discharge SummaryClinic NotesEmergency Room NotesOperative/Procedure NotesBilling/Payment InformationRadiology ImagesRadiology ReportsHistory and PhysicalLabsVerbal Information OnlyPsychiatric/Mental HealthLast 2 yearsOther
Other
Initial to Consent Release of the Following
Mental Health
HIV/AIDS
Genetic Testing
Drug/Alcohol Treatment/Referral/Diagnosis Information
Reproductive Health
Release Instructions

How do you want the information?
Coquille Valley Hospital Contact Information
ADDRESS: 940 East 5th Street Coquille, Oregon 97423
FAX: 541-396-7374
FaxMailPick UpKept on File
Purpose of Release
Treatment/Continuity of CareLegalTransfer of CareOther
I authorize the use and disclosure of my protected health information as described above. I understand that if the person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy laws, the information described below may be re-disclosed and is no longer protected by those regulations. However, I also understand that federal or state law may restrict redisclosure of HIV/AIDS, mental health, genetic testing, and drug/alcohol diagnosis, treatment, or referral information. If the information to be disclosed contains any of the sensitive records listed above, additional laws relating to the use and disclosure of this information may apply. I understand and agree that with my initials, I am allowing this information to be disclosed. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment or determine my eligibility for benefits unless allowed by law. Coquille Valley Hospital is allowed by law 30 days to respond to a request for medical records. I understand that I may inspect, or request copies of any information disclosed by this authorization.
This authorization will expire in 365 days unless specified here
If this authorization is for a research study, the authorization will expire at the end of the research study. I understand that I may revoke this authorization at any time by notifying Coquille Valley Hospital Health Information Management in writing at the above address, except to the extent that action has been taken in reliance on this authorization.
Patient Signature (15 years and up)
Date

MonthDayYear
Representative Signature (Please include supporting documentation)
Relation to Patient
Upload Supporting Documents

Cancelof
Should be Empty:

Authorization for the Use and Disclosure of Protected Health Information

Patient Information

Clinic/Hospital/Healthcare Provider

Receiving Party

Information to be Released

Initial to Consent Release of the Following

Release Instructions

Purpose of Release