Authorization for the Release or Use of
(County Department of Job and Family
Protected Health Information (PHI)
Social Security Number:
(Optional--see reverse side)
I, ________________________________, hereby authorize __________________________________ to disclose protected
(Name of individual)
(Name of covered entity, such as “ODJFS”)
health information to _______________________________ for the purpose of _____________________________________
(Who will receive the information?)
(Describe why this information is being released)
to be mailed to: Street
Is this information being released for an insurance claim?
_____ YES (If YES, see Section II on reverse side.)
The specific protected health information to be released is: ____________________________________________________
(What information should be released?)
By signing below, I understand that:
This authorization shall expire on _________________________ or until revoked by me in writing, whichever comes first.
(Date or completion of “event”)
I have the right to revoke or cancel this authorization at any time by providing notice in writing to:
(insert CDJFS address)
If I revoke or cancel this authorization, it is not effective for the use or for the disclosure of my protected health information
that has already occurred.
Any information used or disclosed as per this specific authorization may be re-disclosed by the person or entity
receiving the information. In such a situation, it may no longer be protected by federal or state law.
I am not required to sign this authorization. If I refuse to sign this form, it will not affect my Medicaid eligibility, my
eligibility for other programs such as Disability Assistance Medical, Refugee Medical, or Healthy Start Healthy Families
or my application for such programs.
I have a right to inspect or copy the protected health information that will be used or disclosed as per this authorization.
If by law we cannot send the protected health information to the entity listed above, please initial in the following space if
you want a copy of the information sent to you directly:__________.
Signature of Individual or Authorized Representative
Print name of individual
Representative’s legal authority to individual
Print name of Authorized Representative
*** Important information and instructions for completing this form are on the reverse side.***