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Options Counseling AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

I authorize Options Counseling & Family Services to use and disclose a copy of the specific health information described below regarding:

Name of Individual: DOB:

Options Location:

My information may be released to or from the following Agency or Name of Individual :
Address:
Phone : Fax :

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. Information used or disclosed on this authorization may be subject to redisclosure and could no longer be protected by federal and state laws on use and disclosure. I understand and agree that this information will be disclosed if I place my initials in the applicable space next to the type of information. Initial each documentation category you are authorizing.

Drug/Alcohol diagnosis, Treatment or referral Information : HIV/AIDS Information :
Genetic Testing : Mental Health Information:

For the purpose of: Legal Care Coordination Other

Items not to be included:

You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure.

You may revoke this authorization verbally or in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage. To revoke this authorization in writing, send a written statement to:
Options Medical Records, 360 E. 10th Ave Ste 450 Eugene, OR 97401.

Clients 14 years of age and older may sign and authorize their own authorizations to release information.
Authority :
Self Parent / Guardian Legal Custodian Legal Custodian Description of personal representative ’s Guardian Other, as listed

To those receiving information under this authorization: The information disclosed to you is protected by state and federal law. You are not authorized to release it to any agency or person not listed on this form without specific written consent of the person to whom it pertains unless authorized by other laws.

I have read this authorization and I understand it
Unless revoked, this release will expire

one year from date of signature

at the end of treatment services

upon the applicable date or event, as listed:

or upon the applicable date or event, as listed:
Date signed

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

April 27, 2020 8:17 am PST

Options Counseling AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Uploaded by Adam Falk - adam.falk@options.org IP 38.79.149.190

April 28, 2020 11:40 am PST

Adam Falk - adam.falk@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

April 28, 2020 11:46 am PST

Adam Falk - adam.falk@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

April 28, 2020 11:53 am PST