Record release to WHHC (English) - West Hills Healthcare

Authorization To Release Health Information

Patient Name(Required)

Date of Birth(Required)

I authorize West Hills Healthcare Clinic to release my health information that I have identified below to:(Required)

Fax

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

To release my health information that I have identified below to:

West Hills Healthcare Clinic 2163 NW 2nd St. McMinnville, OR 97128

Phone (503) 472-4197

Call for fax number if LESS than 20 pages* *RECORDS OVER 20 PAGES MUST BE MAILED

For the purpose of

Expires in 180 days or

Check the spaces below to specifically authorize the release of the following health information and/or records, if such information and/or records exist(Required)

Each of the following items MUST BE CHECKED to be included in the use or disclosure of other health information:

HIV / AIDS related health information and/or records

Mental health information and/or records

Genetic testing information and/or records

Drug/Alcohol diagnosis, treatment and/or referral information (Federal regulations required a description of, and what kind of information is to be disclosed):

Psychotherapy notes (If this authorization is for the use and/or disclosure of psychotherapy notes, then it cannot be combined with another authorization).

Except to the extent that action has already been taken in reliance upon this authorization, I understand that I may revoke this authorization at any time by giving written notice to West Hills Healthcare Clinic.

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment or eligibility for benefits. I may inspect or copy any information to be used or disclosed under this authorization.

I also understand that, if the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing my information under the applicable state or federal law and regulations.

I further understand that the person(s) I am authorizing to use or disclose my information may receive compensation (directly or indirectly) for doing so.

Signature of individual(Required)

Date(Required)

Signature of Legal Representative

Description of Legal Authority

Name

This field is for validation purposes and should be left unchanged.