2111 Exchange Street
Astoria, Oregon 97103
Tel: 503-338-7528
Fax: 503-325-6841
GENERAL OR PSYCHOTHERAPY NOTE AUTHORIZATION
Purpose: This form is used to authorize us to use or disclose protected health information or for another person to
disclose protected health information to us for the purpose stated.
To offset the cost associated with copying, equipment, and supplies, there will be a $15.00 charge for records that
must be paid prior to delivery.
SECTION A: Individual authorizing use and/or disclosure.
Name:
Address:
Telephone:
DOB:
Medical Record Number:
Social Security Number:
SECTION B: The use and/or disclosure being authorized.
Date of service
Operative report
_____________________
Sent To:
From
Lab Reports
_____________________
_________________________________________________
X-Ray Film/Reports _____________________
Individual/Facility / Agency
EKG/EEG
_____________________
Emergency Room
_____________________
_________________________________________________
Address
Discharge Summary _____________________
Physical Therapy
_____________________
_________________________________________________
History and Physical _____________________
City / State / Zip
Progress Notes
_____________________
_________________________________________________
Billing Information
_____________________
Tel Number
Other*
_____________________
_________________________________________________
(*specify)____________________________________
Fax Number
I specifically release the following:
HIV/AIDS/STD's ________
Drug/Alcohol/Mental Health Dx & Tx ________
Genetic Info ________
(Initials)
(Initials)
(Initials)
PATIENT'S SIGNATURE.
I have had full opportunity to read and consider the contents of this authorization, and I understand that, by signing this form, I
am confirming my authorization of the use and/or disclosure of my protected health information, as described in this form.
Patient Signature/Representative:______________________________________________Date: _______________
Personal Representative’s Name:
(Please print)
Relationship to Individual:
Witness:
Purpose of this Authorization:
Insurance
Continuing Care
Legal
Other:__________________________________
1
HIPAA Form 3
Revised 04-20-05