Authorization for Release of Protected Health Information Form

I   First Name   Last Name   Date of Birth:   Date   , hereby authorize   Name of physician or group - example: Occupational Orthopedics    to disclose my protected health information to:
Receiving Party:   Name of recipient   
FAX:  Recipient Fax  
Address:   Recipient Address      City   State   Zip   
Please note we will not email records. An address and/or fax number must be provided.  

Please indicate what item/s you would like sent:
Chart Notes from Occupational Orthopedics   Laboratory results   Diagnostic Imaging Reports         Entire Medical Record   Other: Please indicate what you would like sent. *              
    If other: Please describe what to send         

 
I acknowledge, and hereby consent to such that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or Aids information.   Initial   

Effective Time Period: This consent will expire in 180 days or   Date of your choicefrom the date of signing.

Right to Revoke: I understand that I can cancel permission to use and disclose my information to the individual above at any time in writing. I understand this will not affect information that has already been shared. To revoke Authorization, please send a written statement to Occupational Orthopedics 6464 SW Borland Rd Suite C4, Tualatin, OR 97062 that identifies the date you signed this authorization, the recipient of the information identified in this Authorization, and the state that you are revoking this Authorization.

Authorization: By signing this document, I hereby declare that I understand and acknowledge that I am giving authorization to the use and/or disclosure of my protected health information. 
I am signing this authorization voluntarily. I understand that I have the right to withdraw my permission or withdraw my authorization at any time by writing. In case I withdraw my authorization, I understand that any benefits, treatment, or eligibility shall not be affected.
Further, I understand that this authorization may not further be used by the person or entity to whom my medical records are to be disclosed, to use or disclose the said information to another unless otherwise permitted in writing or unless such intended disclosure is required or permitted by law.