2015 ORS 192.566¹
Authorization form

A health care provider may use an authorization that contains the following provisions in accordance with ORS 192.558 (Use or disclosure by health care provider or state health plan):

______________________________________________________________________________

AUTHORIZATION

TO USE AND DISCLOSE

PROTECTED HEALTH INFORMATION

I authorize: _______________(Name of person/entity disclosing information) to use and disclose a copy of the specific health information described below regarding: _______________(Name of individual) consisting of: (Describe information to be used/disclosed)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

to: _______________(Name and address of recipient or recipients) for the purpose of: (Describe each purpose of disclosure or indicate that the disclosure is at the request of the individual)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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 if I place my initials in the applicable space next to the type of information.

_____ HIV/AIDS information

_____ Mental health information

_____ Genetic testing information

_____ Drug/alcohol diagnosis, treatment, or

referral information.

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

You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure.

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. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage.

To revoke this authorization, please send a written statement to ____________ (contact person) at ____________ (address of person/entity disclosing information) and state that you are revoking this authorization.

I have read this authorization and I understand it. Unless revoked, this authorization expires ________ (insert either applicable date or event).

By: ______________________

(individual or personal representative)

Date: ____________

Description of personal representative’s authority:

___________________________

______________________________________________________________________________ [Formerly 192.522]

Note: See note under 192.553 (Policy for protected health information).

Chapter 192

Atty. Gen. Opinions

Attorney General's Public Meetings and Records Manual, (1973) Vol 36, p 543; public meetings and records manual, (1976) Vol 37, p 1087; pro­hi­bi­­tion on disclosing marriage records, (1998) Vol 49, p 21


1 Legislative Counsel Committee, CHAPTER 192—Records; Public Reports and Meetings, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ors192.­html (2015) (last ac­cessed Jul. 16, 2016).
 
2 Legislative Counsel Committee, Annotations to the Oregon Revised Stat­utes, Cumulative Supplement - 2015, Chapter 192, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ano192.­html (2015) (last ac­cessed Jul. 16, 2016).
 
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.