Authorization to Release/Request for an Individual’s Health Information
Last Name: First: Middle:
Other Names Used: Date of Birth:
Address: City: State:
Home Phone: Work Phone:
I hereby request access to the protected health information in my health record from (date) to (date)
maintained or created by the University Employee Health Plan to the recipient named below.
Entire Health Plan Record *(Excludes Psychotherapy
Psychotherapy Notes* (if checking this box, no other boxes
may be checked. A separate Authorization to
Release/Request for an Individual’s Health Information
must be completed to obtain additional records.)
I will pick up copies of my records
Mail copies of my records to the individual noted below
Provide my records in electronic form: (CD, flashdrive)
Fax my records to:
Purpose of Request: Member’s request, dispute, referral,
I may revoke this Authorization at any time by providing my written revocation to the address at the top of this form. My revocation will
not apply to information already retained, used, or disclosed in response to this Authorization. Unless sooner revoked, the automatic
expiration date of this Authorization will be twelve (12) months from the date of signature.
Unless the purpose of this Authorization is to determine payment of a claim or benefits, the Health Plan may not condition the provision
of treatment or payment for my care on my signing this Authorization.
THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE RECORDS THAT MAY INDICATE THE PRESENCE OF A
COMMUNICABLE DISEASE OR NONCOMMUNICABLE DISEASE.
*The information authorized for release may include protected health information and/or student treatment/education records related to
mental health. Release of mental health records or psychotherapy notes may require consent of the treating provider or a court order.
The information authorized for release may include drug/alcohol abuse treatment records. This category of medical information/records
is protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit anyone receiving this information or record from
making further release unless further release is expressly permitted by the written authorization of the person to whom it pertains or is
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 Member.
As a result, by signing below, I specifically authorize any such records included in my health information to be released.
I agree that costs for records are as follows and are payable prior to the release of the requested records (initial one):
Paper Format – 50 cents per page, plus postage
Digital Format – 30 cents per page plus the cost of the digital media (disk, flash drive, etc.), plus postage
X-ray Film - $5 per x-ray film, plus postage
(Releases in response to subpoenas or requests by attorneys, and insurance companies are charged an additional $10 fee.) Make
checks payable to Cameron University. These fees were set by the Oklahoma legislature.
Signature of M
ember, Parent, or Legal Authorized Representative**
Relationship to M
**May be requested to show proof of representative status
File in Member Chart HIPAA Document
Rev 1/2015 © 2015 Retain for a minimum of 6 years