Authorization To Release PHI

Authorization to release health information/treatment records.
First Name:
Middle Initial:
Last Name:
Other Names Used:
PatientBirthdate
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Alt Phone:
If currently enrolled OU student, enrollment dates: to
I request that the health information (or, if I am a student, my treatment/education record) checked below from: to maintained or created by the Provider named below be released to the Recipient named below.
Initial here if infomation from your records may also be disclosed verbally to the recipient below:
Purpose of Request:
This authorization to release Protected Health Information verbally applies to discussions about information from my:
(Excludes Billing Records/Notes and Psychotherapy Notes)
(Excludes Psychotherapy Notes)
(If checking this box, no other boxes may be checked. A separate copy of this form must be complete to obtain any other types of records.)
OR only these portions of my record:
*The information authorized for release may include information related to mental health. Release of mental health records or psychotherapy notes may require consent of the treating provider or a court order.
Release Records From Provider/Clinic:

Name: OU Graduate Orthodontics
Address: 1201 N Stonewall Ave Rm 442     Oklahoma City, OK, 73117
Phone: 405-271-4148
Fax: 405-271-6012

Provide Records To Recipient:
Recipient Name:
Address:
City:
State:
Zip:
Fax:
Phone:

I understand:

  • I may revoke this Authorization at any time by providing my written revocation to the clinic named in the upper left-hand corner or the University Privacy Official at University of Oklahoma Health Sciences Center, P.O.Box 26901, Oklahoma City, OK 73129. My revocation will not apply to information already retained, used, or disclosed under this Authorization. Unless sooner revoked, the automatic expiration date of this Authorization will be months from the date of signature (12 months, if none entered.)
  • Unless the purpose of this Authorization is to determine payment of a claim or benefits, OU may not condition the provision of treatment or payment for my care on my signing this Authorization.
  • Information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy law. Student treatment/education records may retain continuing privacy protections in accordance with 34 CFR Part 99 (FERPA).
  • The information authorized for release may include substance use disorder records. This category of medical information/records is protected by Federal confidentiality rules (42 CFR Part 2). A general authorization for the release of medical or other information is not sufficient for this purpose. As a result, by signing below, I specifically authorize any such records included in my health information to be released. The Federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient. The Federal rules prohibit anyone receiving this information or record from making further release unless further release is expressly permitted by the written authorization of the person to whom it pertains or is otherwise permitted by 42 CFR Part 2.
  • I agree that costs for records will not exceed the floowing amounts, payable to the University of Oklahome prior to release of the records.
    • Paper Format - 50 cents per page, plus postage and mailer costs.
    • Digial Format - 30 cents per page, plus the cost of digital media (disk, flash drive, etc), plus postage and mailer costs.
    • X-ray/Film - $5 per x-ray/film, plus cost of media, plus postage and mailer costs.
  • There is a $10 fee for certification, affidavit, or similar documentation.
I understand and agree to the statements above and wish to have my records sent to the Recipient via email at
Signature of Patient, Parent, or Authorized Legal Representative**
Relationship To Patient
Date
**May be requested to show proof of representative status