Patient Informed Consent / Refusal (Oregon Department Of Corrections) Page 8
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8P&P P-I-05
Attachment D
HEALTH SERVICES INFORMATION DISCLOSURE
Information obtained within the patient/provider relationship, as well as information contained in a
patient’s health care record is confidential and may not be released except as provided by state
and federal statute, or by order of Oregon or Federal Court. Information given to Health Services
medical and mental health providers is confidential and not shared with anyone outside of Health
Services without written consent with the following exceptions:
Non-Health services staff may be given the patient’s name, services recommended or
provided, provider’s name, dates of treatment, and a brief comment about extent of
participation. Treatment providers may also make recommendations to non-Health
Services staff about ways to help patients with medical or mental health problems
without giving details of diagnosis or medication prescribed.
Non-Health services staff may be given some health information (e.g. diagnosis, symptoms of
decompensation, risk factors, etc.) if:
•
they are currently acting within the official scope of their duties to develop or evaluate
treatment strategies and plans;
•
they are involved in developing correctional plans, medical treatment plans, risk or
behavior management plans or suicide and crisis prevention plans as members (e.g.
designated correctional counselors, mental health housing officers, etc.) of a
multidisciplinary team, treatment team, committee, or other official;
•
they are involved in release planning; or
•
disclosure is necessary for the safety and security of the institution.
Some information obtained in a provider-patient relationship is not confidential and will be
reported to non-Health Services staff and/or other agency personnel as needed even without
written consent of the patient. According to State and Federal laws, this includes knowledge of:
•
danger to self or others;
•
abuse of a child under 18 years of age, abuse of an adult 65 years of age or older, or
abuse of individuals who meet the legal requirement of developmentally disabled or
mentally ill, and a specified victim can be identified;
•
staff physical or sexual abuse of inmates;
•
escape plans or attempts;
•
sexual abuse of or by another inmate.
Confidentiality will not apply to information when it poses an immediate threat to the health and
safety of self, other inmates, staff, or to the community. Reports will be limited to what is
necessary to maintain safety and stay within legal parameters.
My signature below indicates I understand the confidentiality
Inmate Name: _______________________
policy and practices used by HS treatment providers.
SID #: ______________________________
Inmate Comments:
DOB: ________________________________
Inmate Signature____________________________
Date________
Staff Witness Signature____________________________
Date________
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