New Patient Records Request

Name of Facility/Person: Coquille Valley Health and Coquille Valley Hospital
Address: 940 E 5th St, Coquille OR, 97423

Last 2 Years (Clinic Notes, Hospital Discharge, Labs, Radiology, Colonoscopy, and Surgery OP Reports). DO NOT SEND CVH RECORDS

FAX: 541-396-7374

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.

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.