Oklahoma Standard Authorization To Use Or Share Protected Health Information (Phi) Form Page 2
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22.
If checked and initialed, ___________________________________________is authorized to share my protected health
information for the purpose of marketing. I understand ____________________________________________ may receive either
direct or indirect compensation for sharing my information in this case. Individual initials
3. I understand if the person/organization authorized to receive my protected health information is not a health
plan or health care provider, privacy regulations may no longer protect the information.
4. I understand I may inspect or obtain a copy of the protected health information shared under this authorization by sending
a written request to the address listed at the bottom of the form.
B. Signature
This document must be signed by the individual or the individual’s legal representative.
Signature (Patient or Legal Representative)
Date
Printed Patient or Legal Representative Name
Capacity of Legal Representative (if applicable)
Address of entity authorized to release information:____________________________________________________________
_____________________________________________________________________________________________________
The following information is for administrative purposes and may only be completed by an entity that is a “Program” under 42 C.F.R.
Part 2 with respect to alcohol and drug abuse records.
If checked — disclosure of Alcohol or Drug Abuse Records is subject to the following restrictions under 42 C.F.R. Part 2:
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal
rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the
written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release
of medical or other information is NOT sufficient for this purpose. The Federal rules restrict
any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
Oklahoma State Department of Health
ODH 206
Community and Family Health Services/ Administration
HIPAA Document - retain for a minimum of 6 years
January 2012
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