Oklahoma State Department of Health ODH 206
Community and Family Health Services/ Administration HIPAA Document - retain for a minimum of 6 years August 2014
OKLAHOMA STANDARD AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)
Patient Name:_________________________________ Medical Record #:____________________________
Date of Birth:___________________________________ Social Security #:_____________________________
I hereby authorize _______________________________________________________________________________
Name of Person/Organization Disclosing PHI
to release the following information to ________________________________________________________________
Name and Address of Person/Organization Receiving PHI
Information to be shared:
Psychotherapy Notes (if checking this box, no other boxes may be checked) Entire Medical Record
Billing Information for____________________________________ Mental Health Records
Substance Abuse Records Medical information compiled between___________ and ___________
Other:______________________________________________________________________________
The information may be disclosed for the following purpose(s) only:
Insurance Continued Treatment Legal At my or my representative’s request
Other:______________________________________________________________________________
I understand that by voluntarily signing this authorization:
I authorize the use or disclosure of my PHI as described above for the purpose(s) listed.
I have the right to withdraw permission for the release of my information. If I sign this authorization to use or
disclose information, I can revoke this authorization at any time. The revocation must be made in writing to the
person/organization disclosing the information and will not affect information that has already been used or
disclosed.
I have the right to receive a copy of this authorization.
I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing
this authorization will not affect my eligibility for benefits, treatment, enrollment or payment of claims.
My medical information may indicate that I have a communicable and/or non-communicable disease which may
include, but is not limited to diseases such as hepatitis, syphilis, gonorrhea or HIV or AIDS and/or may indicate
that I have or have been treated for psychological or psychiatric conditions or substance abuse.
I understand I may change this authorization at any time by writing to the person/organization disclosing my PHI.
I understand I cannot restrict information that may have already been shared based on this authorization.
Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no
longer be protected by the Privacy Regulation.
Unless revoked or otherwise indicated, this authorization’s automatic expiration date will be one year from the date of my
signature or upon the occurrence of the following event:
________________________________________________ _____________________________________________
Signature of Patient or Legal Representative Date
________________________________________________ _____________________________________________
Description of Legal Representative’s Authority Expiration date (if longer than one year from date of
signature or no event is indicated)
NOT REQUIRED BY ORU
Oklahoma State Department of Health ODH 206
Community and Family Health Services/ Administration HIPAA Document - retain for a minimum of 6 years August 2014
Instructions for Oklahoma Standard Authorization to Use or Share Protected Health Information (PHI)
1. Indicate patient name and date of birth.
2. OPTIONAL: Indicate Medical Record # and/or Social Security #.
3. Indicate the name of person/organization disclosing PHI.
4. Indicate the name and address of person/organization receiving PHI.
Information to be shared:
1. Check the appropriate box.
2. If the information to be shared is not listed, check the “other” box and indicate what information is to be shared in
the space provided.
a. If billing information is shared, indicate which billing information is requested. If all billing information is
requested, just check the box.
b. If psychotherapy notes are requested, no other information can be shared. A separate Authorization
must be completed for additional information.
Purpose for disclosing information:
1. Check the appropriate box.
2. If the purpose is not listed, check the “other” box and indicate the purpose in the space provided.
Expiration Date:
1. Unless otherwise indicated at the bottom of the form, the expiration date is one year from the date of the patient’s
signature or
upon the occurrence of an event chosen by the individual.
a. If the patient chooses an event, list the event in the space provided.
b. If the patient chooses to make the expiration date longer than one year, indicate in the space provided at
the bottom of the form.
Signature:
1. Obtain the signature of the patient or Legal Representative
2. If a Legal Representative signs the form, indicate the description of the Legal Representative’s authority.
Date:
1. The date is the date the form is signed.
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