Name: ________________________
ID: ___________________________
DOB DOB: _________________________
Student Health Services
108 SW Memorial Place Plageman Bldg.
Corvallis, OR 97331
P 541-737-7609 | F 541-737-5528
shsrecords@oregonstate.edu
CONSENT/AUTHORIZATION TO DISCLOSE MEDICAL RECORDS
I hereby consent and authorize the exchange of medical information.
(Instructions on the Back)
1.
Patient Name OSU ID# Date of Birth
2.
Release Records From (Clinician/Facility who has the records now):
Name:
Address:
City/State:
Phone:
Fax:
Email:
3.
Release Records To (whom do you wish to release/exchange records with?) This includes verbal exchange:
Name:
Please check how you would like the records to be
released (If going to another facility Fax or mail is
the only route):
___ Encrypted Email ___ Fax
___ Printed/In Person ___ Mail
Address:
City/State:
Phone:
Fax:
Email:
4.
To release the following information (check all that apply):
Immunizations
Diagnostic imaging reports
Lab reports
Prescription records
TB information, including x-ray if applicable
Most recent annual exam and pap
5.
Initials:
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. I understand and agree that this information will be disclosed
ONLY if I place my INITIALS in the
applicable space next to the type of information.
HIV/AIDS information
Genetic testing information
Drug/alcohol diagnosis, treatment, or referral information
Mental health information
6.
What is the purpose for which this information will be used? (Check the purpose of disclosure):
Continuing Care Internship College Entrance Other:
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 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. To revoke this authorization, please send a written
statement to
Medical Records at OSU Student Health Services, 201 Plageman, Corvallis, OR 97331 and state that you are revoking this authorization. If and
to the degree consent is required to release personally identifiable information in these records under the Family Education Rights and Privacy
Act, 20 USC 1232(g), (collectively referred to as FERPA), this signed document signifies such consent.
I understand that the information used or
disclosed pursuant to this authorization may be subject to disclosure and no longer be protected
under federal law. However, I also understand
that federal or state law may restrict disclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol
diagnosis, treatment or referral information. I have read this authorization and I understand it
.
This authorization is effective immediately and shall remain in effect for one (1) year.
If you would like it to expire sooner please place date here (
not today’s date
)
____/___/___ (date)
Signature of patient or personal representative Today’s Date Your Phone Number
(Go to Page 2)
Name:________________________ Page 2 of 2 Student ID:__________________
Consent/Authorization To Disclose Medical Records
Instructions
Box
1: Put your name, OSU ID#, and date of birth (DOB)
in the appropriate spots.
Box 2: Fill in
Clinician/Name of Facility, Address, Phone number and Fax number (if
available) for the facility that is releasing the medical record information.
Box 3: Fill in
Clinician/Name of Facility, Address, Phone number and Fax number (if
available) for the facility that is receiving the medical record information.
OR
If you are releasing your own information put your contact information on the form.
Select how you would like to receive your medical record information.
Box
4: Check what medical record information you would like to be sent or requested.
Be as specific as you want.
Box
5: Initials need to be placed in the appropriate boxes
, or that information will not
be released from the releasing/sending facility identified in Box 2.
Box 6: Check the appropriate box or boxes for the reason of disclosing
the requested
medical record information.
The form must be signed, dated, and have your phone number
. Without this being
completed the request cannot be processed.
Once the form has been completed it will expire in one year
unless specified or
revoked (in writing) by the patient.
Releasing information to parents
If filling out a “blanket” release form allowing for parents to have access to records and
talk to providers, remember only information from the time the form is released and
backwards can be shared or discussed with the parents. This will not cover any future
information.
I
f filling out the form for a specific condition (i.e. diabetes, concussion), then it is okay
to discuss and share information with the parents about that specific condition. This
type of release of information will be good for up to a year, unless specified or revoked
by the patient.
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