Oklahoma Standard Authorization To Use Or Share Protected Health Information (Phi) Form
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2OKLAHOMA STANDARD AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)
I. INDIVIDUAL INFORMATION (FOR PERSON WHOSE INFORMATION WILL BE SHARED)
Name
Date of Birth
Address
City
Area Code & Telephone Number
State
Zip
II. SCOPE & PURPOSE FOR SHARING INFORMATION
I understand protected health information is information that identifies me. The purpose of this authorization is to allow
to share my protected health information as set forth below, for reasons in addition to
those already permitted by law.
A. Person/Organization Receiving Information and Purpose for Sharing
Persons/Organizations Authorized to Receive My Information
(Name, Address, Phone & Fax)
Relationship
Purpose
B. Information to be shared
1. Check one or more boxes below.
Psychotherapy Notes (if checking this box, no other boxes may be checked
)
Entire Medical Record (
includes all records except Psychotherapy Notes
)
Mental Health Records
Alcohol or Drug Abuse Records
Radiology Report(s)
Pathology Reports
HIV Records
Cardiology Report(s)
Discharge Summary
STD Records
History and Physical
Physician’s Orders
Progress Notes
Operation Reports
Laboratory Report(s)
Medical Images
Consultation Report(s)
Other____________________________________________________________________________________________________
2. Covering Services Between ______________ and ______________ (Insert either date(s) or “all.”)
III. EXPIRATION & REVOCATION
A. This Authorization will Expire (must choose one):
12 months from the date signed in Part IV.B.
Other (insert date or event): ______________________
B. Right to Revoke
I understand I may change this authorization at any time by writing to the address listed at the bottom of this
form. I understand I cannot restrict information that may have already been shared based on this authorization.
IV. ACKNOLEDGEMENTS & SIGNATURES
A. Acknowledgements
1. I understand this authorization is voluntary and will not affect my eligibility for benefits, treatment, enrollment,
or payment of claims.
Revised 01-12
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