2111 Exchange Street
Astoria, Oregon 97103
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.
Medical Record Number:
Social Security Number:
SECTION B: The use and/or disclosure being authorized.
Date of service
X-Ray Film/Reports _____________________
Individual/Facility / Agency
Discharge Summary _____________________
History and Physical _____________________
City / State / Zip
I specifically release the following:
Drug/Alcohol/Mental Health Dx & Tx ________
Genetic Info ________
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:
Relationship to Individual:
Purpose of this Authorization:
HIPAA Form 3