Form 104 - Ohio Northern University Hipaa Compliant Authorization For The Release Of Protected Health Information Page 2


for the following purpose:
Evaluation of my request for accommodations.
I understand that my express consent may be required for the release of information
relating to sexually transmitted diseases, AIDS, mental illness, psychiatric treatment,
and/or drug or alcohol abuse treatment. If I have been tested, treated, or diagnosed in
connection with any such injury, disease, or illness, Provider is specifically authorized to
release those health records (including psychotherapy notes) relating to such diagnosis,
testing, or treatment, as directed in this Authorization. I understand that some of this
health information may be protected under the federal regulations governing the
Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part2, and cannot
be disclosed without my written consent.
This Authorization is a free and voluntary act by me. I understand that, if the Provider is
rendering services to me solely for the purpose of disclosing the health information
generated thereby to the person designated in this Authorization, my failure to provide
this Authorization may result in a denial of service by the Provider. Otherwise, I
understand that my Provider cannot condition my treatment on my signature on this
This Authorization will be valid for one year or until I revoke this Authorization,
whichever occurs first. I know that I may revoke this Authorization at any time, except to
the extent that the Provider may have taken action in reliance thereon, by notifying the
Provider in writing at the address given above. I also understand that the Provider cannot
limit or control the subsequent use, reproduction, or dissemination of the health
information I have authorized to be released. A copy of this Authorization is as valid as
the original.
Individual’s Signature:_______________________________________________
Print name:_______________________________________________________
If applicable:
Personal Representative Signature: ___________________________________
Print name:_______________________________________________________
Description of Personal Representative’s authority to act for the Individual:


00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Page of 2