Peterson Law Offices: Authorization to Disclose Protected Health Information

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

All sections of the authorization must be completed or the authorization will not be considered valid. This authorization must be written, dated and signed by the patient or by a person authorized by law to sign on behalf of the patient.

Name of physician, medical facility or entity disclosing information that I authorize to use and disclose a copy of the specific health information described below.

leave blank

Regarding:

Print name here

DOB

consisting of (initial in the space provided if you are requesting the information described):

Physician Reports*

Initial Here

X-Rays*

Initial Here

Lab Results*

Initial Here

Emergency Dept.*

Initial Here

Billing*

Initial Here

Other, Specify*

Initial here

On or about date injuries/illness occured

Cause of injury:

To: Peterson Law Offices; 825 NE 20th Avenue, Suite 340; Portland, OR 97232 for the purpose of LEGAL MATTERS.
If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed only if I place my initials in the applicable space next to the type of information to be disclosed.

HIV/AIDS information*

Initial here

Mental health information*

Initial Here

Genetic testing information*

Initial Here

Drug/alcohol diagnosis/treatment/referral information*

Initial Here

You do not need to sign this authorization. Refusal to sign this authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstances when refusal to sign to mean you will not receive health services is if the health services are solely for the purpose of providing health information to someone else, in affect your enrollment in a health plan or eligibility for health benefits, unless the authorized information is necessary to determine if you are eligible to enroll in the health plan.
You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any uses or disclosures already make with your permission cannot be undone.
To revoke this authorization, please send a written request to Peterson Law Offices; 825 NE 20th Avenue, Suite 340; Portland, OR 97232 and state that you are revoking this authorization.
I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS information, mental health information, genetic information, drug/alcohol diagnoses, and treatment or referral information.

I have read this authorization and understand it.

Unless revoked, this authorization expires on

Please Leave Blank

By:*

Signature here

Print Name

Date

Please leave blank

Description of personal representative's authority, if applicable:

Use only when a parent/guardian is signing for an injured minor child