Completion of this form is very important – it will allow Salem Psychiatric Associates to understand your medical diagnosis, treatments, and medications, which will help prevent medication errors and support your therapeutic progress.

Please complete this form to allow Salem Psychiatric Associates to share and/or receive relevant health information or records about you, a minor, or a legally incapacitated adult. Specifically, it will allow us to share and/or receive information with the individual, agency, or provider that you authorize, and is solely for the purpose of evaluating your needs, treatment planning, and coordinating your services.

If you are completing this form on behalf of a minor or incapacitated adult, please note that Oregon Law states that any individual 14 years or older must provide their own written consent UNLESS a court or other law authorizes someone other than the individual and/or parent to make treatment decisions.

If you have identified an individual, agency, or provider, please enter their information under Section 2.

By signing this form, I authorize the following THIRD PARTY (individual, school, employer, agency, medical, or other provider) to SHARE AND/OR RECEIVE confidential information about me with Salem Psychiatric Associates. Information to be shared and/or received: 

• Therapy Records
    - including assessments, diagnoses, treatment plans, and progress notes
• Medication Records
    - including assessments, diagnoses, treatment plans, progress  notes, & medication lists
• Laboratory Reports
• Verbal Exchange of Information

If the information contains any of the types of records or information listed below, additional laws relating to use and disclosure may apply. I understand that this information will NOT be shared and/or received unless I place my initials in the space next to the information. Mental Health must be initialed for SPA to coordinate care with this individual or organization:

I understand that I can cancel this authorization at any time. The cancellation will not affect any information that was already disclosed. I understand that state and federal laws protect my health information. I understand what this agreement means, and I approve of the disclosures listed. I am signing this authorization of my own free will. 

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

To be signed by the client (if 14 years or older and able to consent to treatment):

Individuals 14 years or older must provide written consent to treatment unless a court or other law authorizes someone other than the individual and/or parent to make treatment decisions (ORS 109.675).

Using this Form

Terms Used:

Authorized Personal Representative: Someone authorized under State or other applicable law to act on behalf of the individual making health care related decisions.

Assistance: Whenever possible, a SPA staff person should fill out this form with you. Be sure you understand the form before signing. Feel free to ask questions about the form and what it allows. You may substitute a signature with making a mark or by asking an authorized person to sign on your behalf. 

Guardianship/Custody: If the person signing this form is a personal representative, such as a Legal Guardian, a copy of the legal documents that verify the representative's authority to sign the authorization must be attached to this form. Similarly, if an agency has custody, and their representative signs, their custody authority must be attached to this form. 

Cancel: If you later want to cancel this authorization, contact the SPA staff person. You can remove a team member from the form. You may be asked to put the cancellation request in writing. Federal regulations do not require that the cancellation be in writing for Drug and Alcohol Programs. No more information can be disclosed or requested after authorization is cancelled. VMH can continue to use information obtained prior to cancellation.

Minors: If you are a minor, you may authorize the disclosure of mental health or substance abuse information if you are age 14 or older; for the disclosure of any information about sexually transmitted diseases or birth control regardless of your age; for the disclosure of general medical information if you are age 15 or older. 

Special Attention: For information about HIV/AIDS, mental health, genetic testing, or alcohol/drug abuse treatment, the authorization must clearly identify the specific information that may be disclosed.

Re-Disclosure: Federal regulations (42 CFR Part 2) prohibit making any further disclosure of Alcohol and Drug information; state law prohibits further disclosure of HIV/AIDS information (ORS 433.045, OAR 333-12-0270); and state law prohibits further disclosure of mental health, substance abuse treatment, vocational rehabilitation, and developmental disability treatment information from publicly funded programs (ORS 179.505, ORS 344.600) without specific written authorization.