Authorization To Disclose Health Information Form - Oklahoma

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AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
Patient Name:__________________________ Date of Birth: _____________ Social Security Number:____________________
1. I authorize the use or disclosure of the above named individual=s health information as described below:
2. The following individual or organization is authorized to make the disclosure:
______________________________________________________________________________________
Address ________________________________________________________________________________________________
3. The type and amount of information to be used or disclosed is as follows: from (date) __________ to (date) __________
G problem list
G med ication list
X
G psychotherapy notes
G list of allergies
G treatment plan
G imm unization record
G letters &/or forms filled out on behalf of patient
X
G most recent history and physical
G psyc holo gical, p sych o-social, IQ testing & results
G most recent discharge sum mary
G laboratory results
X
G laboratory results
G case managers notes
X
G x-ray an d ima ging rep orts
G physicians notes
X
G consu ltation reports
X
G other
_________________________________________________________________________________________________________
_______________________________________________________________________________________________________
4. THE INFORM ATION AUTH ORIZED FOR RELEA SE MAY INCLUDE INFOR MATION W HICH MA Y INDICATE
THE PRESENCE OF A COMMUNICABLE OR NONCOMMUNICABLE DISEASE, OR RELATE TO MENTAL
HEAL TH, OR D RUG , SUBSTANCE O R ALC OH OL AB USE.
5. This information may be disclosed to and used by the following individual or organization:
_____
Social Security Law C enter
_____
Social Security Law Center
_____
Social Security Law Center
2411 E. Skelly Drive, Ste. 101
3400 Tuxedo Blvd. #D
227 N. M ain
2241
Tulsa, OK 74105
Bartlesville, OK 74006
Miami, OK 74354
918-388-7752
918-335-3100
918-542-8300
918-388-0171 x20 8 fax
918-335-3200 fax
918-542-8302 fax
_____
Social Security Law C enter
th
625 N.W. 13
St
Oklahoma City, OK 73103
405-606-7440
405-606-7441 fax
for the purpo se of: Social Security Disability
6.
I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and
present my written revocation to the health information management department. I understand the revocation will not apply to information
that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when
the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on
one year
the following date, event or condition: _______________. If I fail to specify an expiration date, event or condition, this authorization will
expire in six months.
7.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign
this form in order to assure treatment. I understand that the records requested may be protected under 42 C.F.R., Part 2. Governing Alcohol,
Drug Abuse patient records, the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”), 45 C.F.R. parts 160 & 164, state
laws and regulations regarding the confidentiality of medical records, and cannot be released without my consent unless otherwise provided
by applicable law. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand
any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by
federal confidentiality rules. If I have questions about disclosure of my health information, I can contact (insert HIM director, privacy
officer, or other office or individual’s name or contact information).
___________________________________
________________
Signature of Patient or Legal Representative
Date
___________________________________
___________________________________
If Signed by L egal Rep resen tative, R elation ship to Patien t
Signatu re of W itness

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