Release of Information

Release of Information

Authorization to Use and Disclose Protected Health Information
Records Department Fax: 503-388-3515

Downtown Portland: Phone: 971-251-9856

East Portland Office: Phone: 503-255-2343 Fax:

West Portland Office: Phone: 503-427-2394

Corvallis Office: Phone: 541-320-9555

PO Box 16308, Portland, OR 97292
Instructions
This form is for use by individuals who have been scheduled for their initial appointment at Northwest ADHD Treatment Center, or individuals who are currently patients. Do not submit this form if you have not yet been scheduled for an initial appointment, as we do not retain completed forms for individuals who do not yet have established patient accounts.

Northwest ADHD Treatment Center needs medical records from your primary medical care provider (doctor) to help complete the ADHD evaluation process. To ensure your evaluation is completed as quickly as possible, please be sure you complete this form for your primary medical provider, and complete it again as many times as needed for any current or recent mental health providers, psychologists who completed previous evaluations, friends or family members, or other individuals or entities you would like NW ADHD Treatment Center to communicate with.

Please note, speaking with someone who knows you well is an essential part of the evaluation process, and a completed release of information is needed to talk to anyone about you without you also being present.

You may also prefer a friend, family member, or loved one to be involved in your care. If you would like to limit access, such as to appointment scheduling, or billing information, you can specify exactly what you are allowing us to share under the "Information Which May Be Used/ Disclosed" section, by initialling next to "Other" and completing the "describe:" response area.

Northwest ADHD Patients are entitled to access to their full records at any time. You may use this form at any time to request all or part of your health information on file to date. Your health information may also be available to you already through your portal account.

Only parents or legal guardians may complete this form on behalf of another person.

Patient Information
Patient Name*
Patient Email (you will receive a submission confirmation to the e-mail entered here)*
example@example.com
Date of Birth*

MonthDayYear
Date

Northwest ADHD Treatment Center Provider
NW ADHD Clinician Name(s): This release is valid for all Northwest ADHD Treatment Center clinicians who may be involved in patient's care. Please enter the names of your current provider or providers at Northwest ADHD Treatment Center if you know them.

This information will help us ensure your provider is made aware of your release in a timely manner.
NW ADHD Clinician Names
Release Covered Entity

Please enter with whom you are allowing us to exchange information about you to. Each release only covers one entity that we can communicate with. If you would like to authorize us to exchange information with multiple sources, please complete and submit this form once for each source.
Requesting your own records

If you are requesting your own records, please advance to the next page.
Provider / Clinic/ Other 3rd Party Information
Relationship to Patient : (Medical Provider, Mental Health Provider, School, Spouse, etc):
Provider Clinic 3rd Party Address
Provider/ Clinic/ 3rd Party Phone Number
Provider/ Clinic/ 3rd Party Fax Number

Authorization

If you would like Northwest ADHD Treatment Center to BOTH obtain information and provide information to another party, select BOTH of the top two check boxes.
With my signature below: (Multiple boxes may be checked)

I authorize NW ADHD Treatment Center to REQUEST records and OBTAIN information FROM the party listed belowI authorize NW ADHD Treatment Center to SEND records and PROVIDE information TO the party listed belowVerbal communication ONLY (No exchange of records)
CHECK IF NEEDED

I am requesting my OWN health records from Northwest ADHD Treatment Center. Specify information requested below, for example, "Diagnostic Verification Letter." Personal health records will be made available to you through your patient portal account. If you would like your personal health records provided in a different way, please note how you would like to receive them below.
Personal Health Records Requested (specify exact information sought)

Information Which May be Used/ Disclosed

This section outlines the exact types of information we are authorized to exchange. Place your initials next to all types of information that you consent to Northwest ADHD Treatment Center requesting or disclosing. Initial as many boxes as apply.
Initial for Diagnostic/ Evaluation Records
Initial for Treatment Plan Information
Initial for Treatment Notes/ Progress Notes
Initial for Medical Records
Initial for Other Information (specify below)
Describe Other Information to Exchange if above is initialled
Additional Consent for Certain Types of Information

Please note, as Northwest ADHD Treatment Center is a mental health clinic, you will need to initial at least the Mental Health Information line below to exchange any clinical information.
I understand that other laws about sharing of mental health, HIV/AIDS, genetic, and alcohol/drug treatment information may apply. I understand & agree that this information will be disclosed if I place my initials in the applicable space below:
Initial for Mental Health Information (includes evaluation, behavioral health, and psychiatric treatment related information):
Initial for Genetic Testing Information:
Initial for HIV/ AIDS related Information:
Initial for alcohol/ drug diagnosis, treatment, or referral information:

Final Consent
I understand that I am not required to sign this authorization. If I refuse to sign this, it will not prevent me from getting mental health treatment at Northwest ADHD Treatment Center. The only exception is if the services I am seeking are only for providing health information to someone else and this authorization is needed to make the disclosure.

I may revoke this authorization in writing at any time. If I revoke this authorization, the information described may no longer be used or disclosed for the purposes described here. If Northwest ADHD Treatment Center has already used or disclosed the information, that cannot be undone.

I understand that the information used or disclosed as a result of this authorization may be subject to re-disclosure and no longer protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment or referral information.

To revoke this authorization please send a written statement to the office manager or office staff at the address or fax number listed above and state that you are revoking this authorization, or inform your provider. Unless revoked, this authorization expires 90 days after the completion of treatment.
Patient Signature

Clear
Date

MonthDayYear
Date
Parent Guardian Representative Signature

Clear
Date

MonthDayYear
Date
Print Name of Parent Guardian Representative
Parent Guardian Representatives relationship to patient
Should be Empty:

Release of Information

Instructions

Patient Information

Northwest ADHD Treatment Center Provider

Release Covered Entity

Requesting your own records

Authorization

Information Which May be Used/ Disclosed

Additional Consent for Certain Types of Information

Final Consent