(503) 280-0888 [email protected]

  • 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.
  • leave blank
  • Print name here
  • consisting of (initial in the space provided if you are requesting the information described):
  • Initial Here
  • Initial Here
  • Initial Here
  • Initial Here
  • Initial Here
  • Initial here
  • 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.

  • Initial here
  • Initial Here
  • Initial Here
  • 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.
  • Please Leave Blank
  • Signature here
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  • Use only when a parent/guardian is signing for an injured minor child

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825 NE 20th AVE - Suite 340 Portland , OR 97232-2275 - 503-280-0888
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