Authorization and Consent Form

Family Tree Medical Clinic

2508 NW Medical Park Drive, Roseburg, OR 97471 Phone: 673-5225 Fax: (541) 229-4777 Dr. Sarah Agsten, DO and Dr. Heidi Beery, MD
Protected Health Information Disclosure Authorization and Consent

Please use this form to authorize us to speak to your designated personal contacts
Patient Full Name *
Date of Birth*

MonthDayYear
Date
I, {patientFull} authorize Sarah L. Agsten, D.O. LLC, DBA Family Tree Medical Clinic to use and disclose my medical information described below to the following person(s):
Contact Name
Relationship
Phone Number
Contact Name
Relationship
Phone Number
Contact Name
Relationship
Phone Number
Contact Name
Relationship
Phone Number
I do not wish to authorize any contacts
The health information to be used and disclosed includes the information specifically authorized below as well as all other information in my health records relevant to scheduling/discussing appointments or referrals; disclosing lab and/or imaging results.

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.
Initials   By initialing here, I specifically consent to the disclosure of my HIV/AIDS information.
Initials   By initialing here, I specifically consent to the disclosure of my mental health information.
Initials   By initialing here, I specifically consent to the disclosure of my genetic testing information.
Initials   By initialing here, I specifically consent to the disclosure of my drug/alcohol diagnosis, treatment, or referral information, which requires under federal law a description of how much and what kind of information is to be disclosed.
I have reviewed and I understand this Authorization. I also understand that the information used ordisclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer beprotected under federal law.
Unless revoked in writing, this Authorization expires one year from the date above unless requested otherwise by your initials below in the appropriate section
5 Years       Initial
Never Expires   Initial
Other Date         Date  Initial

Please note: You have the right to revoke this Authorization at any time, provided that you do so in writing, and except to the extent that we have already used or disclosed the information in reliance on this Authorization.
signature of patient or patients personal representative*

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Date*

MonthDayYear
Date
Authority: (if you are signing as personal representative, please add a description of your authority to act for the patient)
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Family Tree Medical Clinic

Protected Health Information Disclosure Authorization and Consent