OHSU Authorization for Disclosure of Health Information
This file contains the authorization form required for the use and disclosure of protected health information by OHSU. It outlines the necessary details for patients to allow the sharing of their medical records. Completing this form ensures compliance with health information regulations.
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How do I fill this out?
Filling out this form is straightforward. Begin by providing your personal information, including your name and account number. Then, specify the details regarding the health information to be disclosed and its intended recipient.
How to fill out the OHSU Authorization for Disclosure of Health Information?
1
Provide your personal information including name and account number.
2
Specify the health information you wish to disclose.
3
Identify the recipient of the information.
4
State the purpose for the disclosure.
5
Sign and date the authorization.
Who needs the OHSU Authorization for Disclosure of Health Information?
1
Patients requiring continued care must authorize disclosure to their healthcare providers.
2
Legal representatives may need this form to access medical records for legal purposes.
3
Schools may request health information for enrollment verification.
4
Insurance companies require authorization to process claims.
5
Any individual wishing to obtain medical records must fill this form.
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What are the instructions for submitting this form?
To submit the completed form, you can fax it to (503) 494-6970 or mail it to Medical Correspondence, Health Information Services, OP17A, OHSU, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098. Make sure all sections are completed to avoid delays. For quick processing, you may consider submitting it via fax.
What are the important dates for this form in 2024 and 2025?
In 2024, important dates related to this form include its annual renewal in April. In 2025, similar deadlines will apply. Always check OHSU for any updated information regarding deadlines.
What is the purpose of this form?
The primary purpose of this form is to authorize the use and disclosure of protected health information. It ensures that individuals have control over who can access their medical records. Moreover, it complies with healthcare regulations to protect patient privacy.
Tell me about this form and its components and fields line-by-line.
- 1. Account No.: Unique number assigned to the patient.
- 2. Medical Record No.: Identification number for the patient's medical records.
- 3. Name: The full name of the individual granting authorization.
- 4. Birthdate: The date of birth of the individual.
- 5. Authorized Individual/Entity: Person or entity authorized to disclose information.
- 6. Recipient Name: The name of the individual or entity receiving the health information.
- 7. Purpose of Disclosure: The reason for requesting the health information.
What happens if I fail to submit this form?
If you fail to submit this form, your request for medical records may be delayed or denied. Ensuring submission is critical for timely access to necessary health information.
- Delays in Care: Without the form, healthcare providers may hesitate to share necessary records, delaying treatment.
- Inability to Process Claims: Insurance claims may be denied or delayed without proper authorization.
- Legal Issues: Legal representatives may be unable to access essential records for court cases.
- Educational Barriers: Schools may not enroll students without verified health information.
- Lack of Continuity of Care: Patients may experience disconnected care without shared medical histories.
How do I know when to use this form?
- 1. Continuing Care: To share information with healthcare providers for ongoing treatment.
- 2. Legal Proceedings: To provide necessary medical records in court cases.
- 3. Insurance Claims: To process insurance claims that require disclosure of health records.
- 4. School Enrollment: To provide health history for enrollment in educational institutions.
- 5. Personal Requests: To allow individuals to obtain their medical records.
Frequently Asked Questions
What is this form for?
This form is used to authorize the use and disclosure of protected health information.
Who can fill out this form?
Patients, legal representatives, and healthcare providers can fill out this form.
How do I submit the form?
You can submit the form via fax or by mailing it to the provided address.
What happens after I submit the form?
Your health information request will be processed once the form is received.
Is there a time limit on this authorization?
The authorization expires one year after signing unless specified otherwise.
What if I want to revoke this authorization?
You can revoke your authorization by sending a written statement to the designated address.
Can I specify who receives my information?
Yes, you can specify the recipient in the designated section of the form.
What if I need to add more information?
Use the 'Other' section to specify any additional details not covered on the form.
Can this form be used for all types of medical records?
Yes, this form can be used for various types of medical records as listed in the document.
How can I contact OHSU for more information?
You can contact OHSU through the provided phone number or mailing address.
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