AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

FAMILY TREE MEDICAL CLINIC

Dr. Sarah Agsten and Dr. Heidi Beery
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

(Please complete this form in its entirety)
Patient Full Legal Name*
Date of Birth*

MonthDayYear
Date
Reason for release*

Continuation of Medical CareTransfer of CareLegalOther
INFORMATION TO BE RELEASED BY:
Family Tree Medical Clinic Other Name of Facility/Provider/Person Address (If Known) Phone Number* Fax Number (If Known)
INFORMATION TO BE RELEASED TO:
Family Tree Medical Clinic Other Name of Facility/Provider/Person Address (If Known) Phone Number* Fax Number (If Known)
Please indicate the last time you were seen at the requested office in order to better locate your records*

Present to 2 years3-5 years6-10 yearsOver 10 years
Please indicate what medical information is being requested:*

All Records (Limited to the last 2 years)Other
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 the above-described purpose.

Please note that Oregon Law requires separate consents for the below information. You must initial each section in order for your records to be released even if they do not apply to you specifically.

Initial*   By initialing here, I specifically consent to the disclosure of my HIV/AIDS information

Initial*   By initialing here, I specifically consent to the disclosure of my mental health information

Initial*   By initialing here, I specifically consent to the disclosure of my genetic testing information

Initial*   By Initialing here, I specifically consent to the disclosure of my drug and 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.
Signature of patient or legal guardian*

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Today's Date*

MonthDayYear
Date
Print guardian name (If applicable)
If we, the healthcare provider, are requesting this Authorization from you for our own use and disclosure or to allow another healthcare provider or health plan to disclose information to us:

1. We cannot condition our provision of services or treatment to you on the receipt of this signed authorization

2.You may inspect a copy of the protected health information to be used or disclosed

3.You may refuse to sign this Authorization; and

4.We must provide you with a copy of the signed Authorization.

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 or to the extent you signed this Authorization as a condition to insurance coverage. To revoke this Authorization, please contact our Privacy Officer.
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FAMILY TREE MEDICAL CLINIC

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION