2021 Oregon Revised Statutes
Chapter 192 - Records; Public Reports and Meetings
Section 192.566 - Authorization form.


______________________________________________________________________________
AUTHORIZATION
TO USE AND DISCLOSE
PROTECTED HEALTH INFORMATION
I authorize: _______________ (Name of person/entity disclosing information) to use and disclose a copy of the specific health information described below regarding: _______________ (Name of individual) consisting of: (Describe information to be used/disclosed)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
to: _______________ (Name and address of recipient or recipients) for the purpose of: (Describe each purpose of disclosure or indicate that the disclosure is at the request of the individual)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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 if I place my initials in the applicable space next to the type of information.
_____ HIV/AIDS information
_____ Mental health information
_____ Genetic testing information
_____ Drug/alcohol diagnosis, treatment, or
referral information.
I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict redisclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol diagnosis, treatment or referral information.
PROVIDER INFORMATION
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. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage.
To revoke this authorization, please send a written statement to ____________ (contact person) at ____________ (address of person/entity disclosing information) and state that you are revoking this authorization.
SIGNATURE
I have read this authorization and I understand it. Unless revoked, this authorization expires ________ (insert either applicable date or event).
By: ______________________
Date: ____________
Description of personal representative’s authority:
___________________________
______________________________________________________________________________ [Formerly 192.522]
Note: See note under 192.553.

Structure 2021 Oregon Revised Statutes

2021 Oregon Revised Statutes

Volume : 05 - State Government, Government Procedures, Land Use

Chapter 192 - Records; Public Reports and Meetings

Section 192.001 - Policy concerning public records.

Section 192.005 - Definitions for ORS 192.005 to 192.170.

Section 192.018 - Written policies on use, retention and ownership of public records; State Archivist approval.

Section 192.105 - State Archivist authorization for state officials to dispose of records; legislative records excepted; local government policy on disposing of public records; limitations; records officer; standards for State Records Center.

Section 192.170 - Disposition of materials without authorization.

Section 192.173 - Records and reports required by law to be in English; penalty.

Section 192.180 - Coordination of executive department response to public records request.

Section 192.183 - Compiling public records stored in electronic form; rules.

Section 192.191 - Department of Justice information sharing guide.

Section 192.210 - Definitions for ORS 192.210 and 192.220.

Section 192.220 - Standardized report forms; exemptions.

Section 192.230 - Definitions for ORS 192.235 to 192.245.

Section 192.235 - Policy for ORS 192.230 to 192.250.

Section 192.240 - Duties of state agency issuing report.

Section 192.243 - Availability of report on Internet; rules.

Section 192.245 - Form of report to legislature.

Section 192.250 - Director of Oregon Department of Administrative Services to report to legislature on ORS 192.230 to 192.250.

Section 192.270 - Definitions for ORS 192.270 and 192.275.

Section 192.275 - Notice when report required; content; effect.

Section 192.311 - Definitions for ORS 192.311 to 192.478.

Section 192.314 - Right to inspect public records; notice to public body attorney.

Section 192.318 - Functions of custodian of public records; rules.

Section 192.324 - Copies or inspection of public records; public body response; fees; procedure for records requests.

Section 192.329 - Public body’s response to public records request.

Section 192.335 - Immunity from liability for disclosure of public record; effect of disclosure on privilege.

Section 192.340 - Attorney General catalog of exemptions from disclosure.

Section 192.345 - Public records conditionally exempt from disclosure.

Section 192.355 - Public records exempt from disclosure.

Section 192.360 - Condensation of public record subject to disclosure; petition to review denial of right to inspect public record; adequacy of condensation.

Section 192.363 - Contents of certain requests for disclosure.

Section 192.365 - Disclosure of information pertaining to home care worker, personal support worker, operator of child care facility, exempt child care provider or operator of adult foster home.

Section 192.368 - Nondisclosure on request of home address, home telephone number and electronic mail address; rules of procedure; duration of effect of request; liability; when not applicable.

Section 192.371 - Nondisclosure of public employee identification badge or card.

Section 192.374 - Nondisclosure of concealed handgun license records or information; exceptions; limitations; rules.

Section 192.377 - Required redaction of certain personal information.

Section 192.380 - Immunity from liability for disclosure of certain personal information; recovery of costs.

Section 192.385 - Nondisclosure of certain public safety officer investigation records; exceptions.

Section 192.390 - Inspection of records more than 25 years old.

Section 192.395 - Health services costs.

Section 192.398 - Medical records; sealed records; records of individual in custody or under supervision; student records.

Section 192.401 - Records of health professional regulatory boards, Health Licensing Office.

Section 192.407 - When petition for review of public records request allowed; order granting petition; penalty.

Section 192.411 - Petition to review denial of right to inspect state public record; appeal from decision of Attorney General denying inspection.

Section 192.415 - Procedure to review denial of right to inspect other public records; effect of disclosure.

Section 192.418 - Effect of failure of Attorney General, district attorney or elected official to take timely action on inspection petition.

Section 192.422 - Petition form; procedure when petition received.

Section 192.431 - Court authority in reviewing action denying right to inspect public records; docketing; costs and attorney fees.

Section 192.461 - Public Records Advocate.

Section 192.464 - Facilitated dispute resolution services of Public Records Advocate.

Section 192.475 - Public records request training.

Section 192.477 - Public Records Advocate Fund.

Section 192.481 - Public Records Advisory Council.

Section 192.483 - Duties of Public Records Advisory Council; rules.

Section 192.485 - Definitions for ORS 192.485 to 192.513.

Section 192.488 - Open government impact statement.

Section 192.492 - Notification of change to public records laws.

Section 192.499 - Public records subcommittee.

Section 192.508 - Rules.

Section 192.511 - Oregon Sunshine Committee; membership; duties; rules.

Section 192.513 - Review of exemptions from disclosure by Oregon Sunshine Committee.

Section 192.515 - Definitions for ORS 192.515 and 192.517.

Section 192.517 - Access to records of individual with disability or individual with mental illness.

Section 192.531 - Definitions for ORS 192.531 to 192.549.

Section 192.533 - Legislative findings; purposes.

Section 192.535 - Informed consent for obtaining genetic information.

Section 192.537 - Individual’s rights in genetic information; retention of information; destruction of information.

Section 192.538 - Notice by health care provider regarding anonymous or coded research.

Section 192.539 - Disclosure of genetic information; exceptions.

Section 192.540 - Use of deceased individual’s DNA sample or genetic information for research.

Section 192.541 - Private right of action; remedies; affirmative defense; attorney fees.

Section 192.543 - Criminal penalty.

Section 192.545 - Enforcement; Attorney General or district attorney; intervention.

Section 192.547 - Oregon Health Authority rules; procedures.

Section 192.549 - Advisory Committee on Genetic Privacy and Research.

Section 192.551 - Health care records at colleges, universities.

Section 192.553 - Policy for protected health information.

Section 192.556 - Definitions for ORS 192.553 to 192.581.

Section 192.558 - Use or disclosure by health care provider or state health plan.

Section 192.561 - Disclosure by health care provider in coordinated care organization.

Section 192.563 - Health care provider and state health plan charges.

Section 192.566 - Authorization form.

Section 192.567 - Disclosure without authorization form.

Section 192.568 - Confidentiality; use and disclosure.

Section 192.571 - No right of action.

Section 192.573 - Personal representative of deceased individual.

Section 192.576 - Disclosure to individual appealing denial of Social Security benefits.

Section 192.577 - Disclosure of information concerning adult in custody of Department of Corrections.

Section 192.579 - Allowed disclosure for coordinating care.

Section 192.581 - Allowed retention or disclosure of genetic information.

Section 192.582 - Confidentiality of bedbug infestation reports.

Section 192.583 - Definitions for ORS 192.583 to 192.607.

Section 192.586 - Disclosure of financial records prohibited; exceptions.

Section 192.588 - Disclosure to Department of Human Services or Oregon Health Authority; procedure; limitations.

Section 192.589 - Financial institution records of deceased individual; disclosure to Department of Human Services or Oregon Health Authority; procedure.

Section 192.591 - Disclosure to state court; procedure; limitations.

Section 192.593 - Authorization by customer for disclosure.

Section 192.596 - Disclosure under summons or subpoena; procedure.

Section 192.597 - Disclosure pursuant to abuse investigation; procedure; liability; affidavit.

Section 192.598 - Disclosure under search warrant.

Section 192.600 - Liability of financial institution for disclosure.

Section 192.602 - Time for compliance; reimbursement; exceptions.

Section 192.603 - Procedure for disclosure to law enforcement agency.

Section 192.606 - Civil liability for violation of ORS 192.583 to 192.607; attorney fees; status of evidence obtained in violation.

Section 192.610 - Definitions for ORS 192.610 to 192.690.

Section 192.630 - Meetings of governing body to be open to public; location of meetings; accommodation for person with disability; interpreters.

Section 192.640 - Public notice required; special notice for executive sessions or special or emergency meetings.

Section 192.650 - Recording or written minutes required; content; fees.

Section 192.660 - Executive sessions permitted on certain matters; procedures; news media representatives’ attendance; limits; advisory opinions.

Section 192.670 - Meetings by means of telephone or electronic communication.

Section 192.672 - State board or commission meetings through telephone or electronic means; compensation and reimbursement.

Section 192.680 - Enforcement of ORS 192.610 to 192.690; effect of violation on validity of decision of governing body; liability of members.

Section 192.685 - Additional enforcement of alleged violations of ORS 192.660.

Section 192.690 - Exceptions to ORS 192.610 to 192.690.

Section 192.695 - Prima facie evidence of violation required of plaintiff.

Section 192.715 - Short title.

Section 192.720 - Definitions for ORS 192.715 to 192.760.

Section 192.725 - Electronic record as official record.

Section 192.730 - Authentication of electronic official record.

Section 192.735 - Evidentiary rules concerning authenticated electronic record.

Section 192.740 - Preservation and security of electronic official record.

Section 192.745 - Availability for public use.

Section 192.750 - Implementation; considerations.

Section 192.755 - Uniform construction.

Section 192.760 - Relationship of ORS 192.715 to 192.760 to federal law.

Section 192.800 - Definitions for ORS 192.800 to 192.810.

Section 192.805 - Reimbursement required prior to disclosure; charges.

Section 192.820 - Definitions for ORS 192.820 to 192.868.

Section 192.822 - Address Confidentiality Program; substitute addresses.

Section 192.826 - Application for participation in program; certification of participation; authorization card; rules.

Section 192.828 - Prohibitions; civil penalty.

Section 192.832 - Notice of change in name, address or telephone number.

Section 192.834 - Cancellation of certification.

Section 192.836 - Use of substitute address; waiver of requirement.

Section 192.842 - Use of actual or substitute address in specified circumstances.

Section 192.844 - Prohibition on disclosure of actual address or telephone number by public body.

Section 192.846 - Records of Department of Transportation; substitute address.

Section 192.848 - When Attorney General may disclose actual address or telephone number.

Section 192.852 - Prohibition on obtaining actual address or telephone number; prohibition on disclosure by employee of public body.

Section 192.854 - Application assistants; application assistance not legal advice.

Section 192.856 - Additional response time for notice or other paper.

Section 192.858 - Disclosures to participants.

Section 192.860 - Rules.

Section 192.865 - Criminal penalty.

Section 192.868 - Grants, donations and gifts.