Odh 206 - Oklahoma Standard Authorization To Use Or Share Protected Health Information (Phi) Page 2

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Instructions for Oklahoma Standard Authorization to Use or Share Protected Health Information (PHI)
1. Indicate patient name and date of birth.
2. OPTIONAL: Indicate Medical Record # and/or Social Security #.
3. Indicate the name of person/organization disclosing PHI.
4. Indicate the name and address of person/organization receiving PHI.
Information to be shared:
1. Check the appropriate box.
2. If the information to be shared is not listed, check the “other” box and indicate what information is to be shared in
the space provided.
a. If billing information is shared, indicate which billing information is requested. If all billing information is
requested, just check the box.
b. If psychotherapy notes are requested, no other information can be shared. A separate Authorization
must be completed for additional information.
Purpose for disclosing information:
1. Check the appropriate box.
2. If the purpose is not listed, check the “other” box and indicate the purpose in the space provided.
Expiration Date:
1. Unless otherwise indicated at the bottom of the form, the expiration date is one year from the date of the patient’s
signature or upon the occurrence of an event chosen by the individual.
a. If the patient chooses an event, list the event in the space provided.
b. If the patient chooses to make the expiration date longer than one year, indicate in the space provided at
the bottom of the form.
Signature:
1.
Obtain the signature of the patient or Legal Representative
2. If a Legal Representative signs the form, indicate the description of the Legal Representative’s authority.
Date:
1. The date is the date the form is signed.
Oklahoma State Department of Health
ODH 206
Community and Family Health Services/ Administration
HIPAA Document - retain for a minimum of 6 years
August 2014

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