Records Release Authorization Form

I authorize (name of facility) - (Enter the name of the practice we are requesting records from - NOT Oregon Pain and Spine and NOT yourself)

to release the specific health information described below regarding:

Patient Name

Date of Birth

Date

To (name and address of recipient)

Enter "Oregon Pain & Spine" if sending to our practice

Address or Fax Number

For the purpose of

(describe each purpose of disclosure or indicate that the disclosure is at the request of the individual)

Information to be disclosed

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 a mark next to the type of 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.

NOTICE

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 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. 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 Oregon Pain & Spine Specialists, 360 S. Garden Way, Ste 230, Eugene, Oregon 97401.

I have read this authorization and I understand it. Unless revoked, this authorization expires(insert either applicable date or event):

Signature of Individual or Personal Representative

Date

Description of personal representative’s authority (if applicable)

RETURN SIGNED FORM TO FAX@OREGONPAINANDSPINE.COM

360 S GARDEN WAY, STE #230, EUGENE, OR 97401 ♦ PHONE: 541.844.7246 ♦ FAX: 541.844.0598

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION