© 10/2020 File in Patient Chart HIPAA Document
Retain for a minimum of 6 years
The University of Oklahoma
OU#Health#Services
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Goddard Health Center
620 Elm Avenue
Norman, OK 73019-3136
Authorization to Release Health Information/Treatment Records
If currently enrolled OU student, enrollment dates:
• I request that the health information (or, if I am a student, my treatment/education record) checked below from, (date)_____________ to (date)
________________ maintained or created by the Provider named below be released to the Recipient named below.
• Initial here if information from your records may also be disclosed verbally to the recipient below:____________
Purpose of Request: referral legal transfer other:____________________________________________________________
The records I request access to or a copy of are:
Entire Health Record*
Excludes Billing Records/Notes and Psychotherapy
OR only these portions of my record:
X-ray Reports/Films Immunization Records
Entire Health Record plus Billing Records/Notes*
Excludes Psychotherapy Notes*
Discharge Summaries Medications
Billing Records Pathology/Lab Reports
Psychotherapy Notes* (if checking this box, no other boxes may be
checked. A separate copy of this form must be completed to
obtain any other types of records.)
Other: ________________________________________
________________________________________________
*The information authorized for release may include information related to mental health. Release of mental health records or psychotherapy notes
may require consent of the treating provider or a court order.
Release Records From Provider/Clinic:
Provide Records To Recipient:
• I may revoke this Authorization at any time by providing my written revocation to the address at the bottom of this form. My revocation will not
apply to information already retained, used, or disclosed under this Authorization. Unless sooner revoked, the automatic expiration date of this
Authorization will be ________ months from the date of signature (12 months, if none entered).
• Unless the purpose of this Authorization is to determine payment of a claim or benefits, OU may not condition the provision of treatment or
payment for my care on my signing this Authorization.
• Information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy
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w. Student treatment/education records may retain continuing privacy protections in accordance with 34 CFR Part 99 (FERPA).
• 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 substance use disorder records. This category of medical information/records is protected by
Federal confidentiality rules (42 CFR Part 2). A general authorization for the release of medical or other information is not sufficient for this
purpose. As a result, by signing below, I specifically authorize any such records included in my health information to be released. The Federa
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les restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. 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.
• I agree that costs for records will not exceed the following amounts, payable to the University of Oklahoma prior to the release of the records:
- Paper Format – 50 cents per page, plus postage and mailer costs
- Digital Format – 30 cents per page, plus the cost of the digital media (disk, flash drive, etc.), plus postage and mailer costs
- X-ray/Film - $5 per x-ray/film, plus cost of media, plus postage and mailer costs
• There is $10 fee for certification, affidavit, or similar documentation.
Recipient will pick up copies of my records when called
Mail copies of my records to the Recipient address above
Fax my records to the Recipient : (____) ___________________
Other (if available): _________________________________
I understand the security of email cannot be guaranteed and that unauthorized individuals may be able to access the message. I
understand the information sent via electronic communication may include information that may indicate the presence of a communicable
disease or non-communicable disease, mental health records, or substance use disorder records. It is my responsibility to notify OU if
the email address information changes after submitting this form. I understand and agree to the statements above and wish to have
my records sent to the Recipient via email at: ___________________________________________@_____________________.
Signature of Patient, Parent, or Authorized Legal Representative**
**May be requested to show proof of representative status
University of Oklahoma Health Sciences Center, University Privacy Official, P. O. Box 26901, Oklahoma City, OK 73129
