HIPAA FORM 3
ONEIDA COMMUNITY HEALTH CENTER
Purpose: This form is used for an individual to authorize use or disclosure of the individual's protected health
information for the purposes stated.
SECTION A: Psychotherapy notes.
Check if this authorization is for psychotherapy notes.
If this authorization is for psychotherapy notes, you must not use it as an authorization for any other type of
protected health information.
SECTION B: Individual authorizing use and/or disclosure.
Telephone: ____________________________________________ E-mail: __________________________________
Date of Birth: ____________________________________________ Social Security Number: ______________________
TO THE INDIVIDUAL: Please Read the following and complete the information requested.
No Conditions: This authorization is voluntary. We will not condition your treatment on receiving this authorization.
Effect of Granting this Authorization: The protected health information described below may be disclosed to and/or
received by persons or organizations who are not subject to federal health information privacy laws. These persons
or organizations may further disclose the protected health information, and it may no longer be protected by federal
health information privacy laws.
SECTION C: The use and/or disclosure being authorized.
Purpose of this Authorization:
At request of individual (or the individual's personal representative).
For the following purposes:
Protected Health Information to Be Use and/or Disclosed:
Specifically and meaningfully describe the
protected health information that this authorization will allow to be used and/or disclosed:
Entities Authorized to Use or Disclose:
Name or specifically describe the persons and/or organizations (or
the classes of persons and/or organizations), including us, who will be authorized to make use of and/or to disclose
the protected health information described above:
From: Oneida Community Health Center Phone: (920)869-2711
Address: P.O. Box 365 City, State, Zip: Oneida, WI 54155