Odh 206 - Oklahoma Standard Authorization To Use Or Share Protected Health Information (Phi)
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2OKLAHOMA STANDARD AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)
Patient Name:_________________________________
Medical Record #:____________________________
Date of Birth:___________________________________
Social Security #:_____________________________
I hereby authorize _______________________________________________________________________________
Name of Person/Organization Disclosing PHI
to release the following information to ________________________________________________________________
Name and Address of Person/Organization Receiving PHI
Information to be shared:
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Psychotherapy Notes (if checking this box, no other boxes may be checked)
Entire Medical Record
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Billing Information for____________________________________
Mental Health Records
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Substance Abuse Records
Medical information compiled between___________ and ___________
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Other:______________________________________________________________________________
The information may be disclosed for the following purpose(s) only:
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Insurance
Continued Treatment
Legal
At my or my representative’s request
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Other:______________________________________________________________________________
I understand that by voluntarily signing this authorization:
•
I authorize the use or disclosure of my PHI as described above for the purpose(s) listed.
•
I have the right to withdraw permission for the release of my information. If I sign this authorization to use or
disclose information, I can revoke this authorization at any time. The revocation must be made in writing to the
person/organization disclosing the information and will not affect information that has already been used or
disclosed.
•
I have the right to receive a copy of this authorization.
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I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing
this authorization will not affect my eligibility for benefits, treatment, enrollment or payment of claims.
•
My medical information may indicate that I have a communicable and/or non-communicable disease which may
include, but is not limited to diseases such as hepatitis, syphilis, gonorrhea or HIV or AIDS and/or may indicate
that I have or have been treated for psychological or psychiatric conditions or substance abuse.
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I understand I may change this authorization at any time by writing to the person/organization disclosing my PHI.
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I understand I cannot restrict information that may have already been shared based on this authorization.
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Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no
longer be protected by the Privacy Regulation.
Unless revoked or otherwise indicated, this authorization’s automatic expiration date will be one year from the date of my
signature or upon the occurrence of the following event:____________________________________________________
_________________________________________________________________________________________________
________________________________________________
_____________________________________________
Signature of Patient or Legal Representative
Date
________________________________________________
_____________________________________________
Description of Legal Representative’s Authority
Expiration date (if longer than one year from date of
signature or no event is indicated)
Oklahoma State Department of Health
ODH 206
Community and Family Health Services/ Administration
HIPAA Document - retain for a minimum of 6 years
August 2014
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