Edit, Download, and Sign the OHSU Authorization to Use and Disclose Health Information
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How do I fill this out?
To complete this form, begin by filling out the patient identification information. Next, specify the health information to be disclosed. Finally, indicate the intended recipient and purpose for the disclosure.
How to fill out the OHSU Authorization to Use and Disclose Health Information?
1
Fill out the patient identification section.
2
Indicate the health information to be disclosed.
3
Specify the recipient's name and address.
4
Provide the purpose of the disclosure.
5
Sign and date the authorization.
Who needs the OHSU Authorization to Use and Disclose Health Information?
1
Patients needing to share medical records with a new healthcare provider.
2
Individuals requiring information for legal purposes.
3
Students needing health records for school enrollment.
4
Patients transferring care to a different medical facility.
5
Individuals applying for disability benefits that require medical documentation.
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1
Upload the PDF document to PrintFriendly.
2
Utilize the editing tools to modify text and fields.
3
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4
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5
Download or share the edited PDF as desired.
What are the important dates for this form in 2024 and 2025?
Important submission dates for this form include annual renewals starting from the signing date. Ensure that you manage your health information disclosures appropriately each year. Check with OHSU for specific deadlines related to your health services.
What is the purpose of this form?
The purpose of this form is to authorize healthcare providers to use and disclose an individual's protected health information. It serves as a formal request for specific medical records that may be needed for continuity of care or other legal purposes. By filling out this form, patients can ensure their health information is shared as they intend.
Tell me about this form and its components and fields line-by-line.
- 1. Account Number: The unique identifier for your medical account.
- 2. Medical Record Number: Your specific medical record identification number.
- 3. Name: The full name of the patient.
- 4. Birthdate: The date of birth of the patient.
- 5. Disclosure Details: Specify what information is being authorized for use.
- 6. Recipient Information: Name and address of who will receive the information.
- 7. Purpose of Disclosure: Reason for sharing the health information.
- 8. Signature: The patient's or authorized representative's signature.
- 9. Date: The date the authorization is signed.
What happens if I fail to submit this form?
If this form is not submitted correctly, the authorization may not be honored. As a result, your health information may remain undisclosed, which can delay important health services. It is crucial to ensure all sections are completed and accurate.
- Delay in Services: Incomplete submission may cause delays in receiving necessary medical services.
- Non-Compliance: Submitting an incomplete form may result in non-compliance with health information requests.
- Legal Issues: Failure to complete the authorization may lead to legal challenges in disclosing required information.
How do I know when to use this form?
- 1. Transition to New Healthcare Provider: Use when changing providers to transfer relevant health information.
- 2. Legal Documentation: Required when legal representation needs access to health records.
- 3. Educational Needs: Utilized for school admissions that require proof of health literacy.
Frequently Asked Questions
What is the purpose of this authorization form?
This form allows patients to authorize the use and disclosure of their protected health information.
Can I edit this document online?
Yes, you can use PrintFriendly's tools to edit this PDF conveniently.
Who can I share this PDF with?
You can share this PDF with medical providers, legal representatives, or anyone you designate.
What happens if I don't fill it out completely?
Incomplete forms may not be accepted, and the authorization may be considered invalid.
Can I save this edited PDF?
You can download the edited document directly after making your changes.
Is there a way to revoke this authorization?
Yes, you can revoke your authorization by sending a written statement to the provided address.
What types of health information can I disclose?
You can specify various types of health records, including mental health records, lab results, and immunization records.
Do I need to sign this form?
Yes, your signature is required unless you choose to revoke the authorization.
What should I do if I have questions about my rights?
You can contact the Health Information Services department for assistance.
Can this form be used for school entry?
Yes, it can be used to provide necessary health information for school enrollment.
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