Oklahoma Consent for Release of Information Oklahoma by xgr11556

VIEWS: 83 PAGES: 2

More Info
									                                        AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

Patient’s Name ________________________________________________________________________________ Date of Birth _________________

Address ____________________________________________________________________________________________________________________

I the undersigned, do hereby authorize the _____________Oklahoma State Department of Health


                                                                       (Releasing Agency or Individual)

to release Blood Lead testing results                                                                                     information from my
                                                         (Describe Type)
_child’s                                                                                                         Record(s) to the following:

____________________________________________________________________________________________________________________________
                          (Name of person, agency or firm authorized to receive information)

____________________________________________________________________________________________________________________________
                                                          (Address)

                                                    NOTICE
                                            (63 O.S. 1992, 1-502.2.B.)
THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE RECORDS WHICH MAY INDICATE THE PRESENCE OF A
COMMUNICABLE OR NONCOMMUNICABLE DISEASE. YOU MAY STOP ANY FURTHER RELEASE OF THIS INFORMATION BY
REVOKING THIS AUTHORIZATION BY WRITTEN NOTICE TO THE OFFICE AUTHORIZED ABOVE TO MAKE THIS RELEASE.

Information may be released to the above named persons until __one year from the date of parent/guardian’s signature
                                                                            Date

           __________________                      _________________________________________________________
                   Date                                              (Signature of patient*)

           __________________                      _________________________________________________________
                   Date                                    (Signature of guardian or authorized individual)

                                                   _________________________________________________________
                                                           (Relationship to patient or authority to release)

Witness (1) _________________________________________

           (2) _________________________________________                                                  THE CLIENT MUST RECEIVE
                  (Signature by mark must have 2 witnesses)                                               A COPY OF THIS SIGNED
                                                                                                          AND/OR DATED DOCUMENT
*Services will not be refused to you (patient) if you choose not to sign this form.

                                                       NOTICE TO ABOVE NAMED RECIPIENTS

CERTAIN STATUTES, STATE AND FEDERAL, MAY PROHIBIT FURTHER DISCLOSURES OR RELEASE OF THE ABOVE INFORMATION
WITHOUT SPECIFIC WRITTEN CONSENT FOR RELEASE FROM THE PERSON(S) ABOUT WHOM IT PERTAINS. THIS “AUTHORIZATION
TO RELEASE CONFIDENTIAL INFORMATION” IS NOT INTENDED TO AUTHORIZE FURTHER RELEASE OR DISCLOSURE, OR TO
CONSTITUTE A WAIVER OF SUCH OTHER STATUTES. HOWEVER, INFORMATION RELEASED BY THIS AUTHORIZATION MAY BE
SUBJECT TO REDISCLOSURE BY THE RECIPIENT AND WILL NO LONGER BE PROTECTED.

FOR COUNTY HEALTH DEPARTMENT USE:

SPECIFIC INFORMATION RELEASED                          TO WHOM INFORMATION WAS RELEASED                          BY                  DATE

____________________________________               _______________________________________________        ____________ __       ___ ___________

____________________________________               _______________________________________________        _______________       ___ ___________

____________________________________               _______________________________________________        _______________       ___ ___________


Oklahoma State Department of Health                                                                                          ODH Form No. 206
Community Health Services                                                                                                    (REV. 11/07)
                                                   ODH Form No. 206


DESCRIPTION

This form is designed for use in obtaining authorization for the release of information on a specific record in the
County Health Department. It can be used to obtain consent for release of information to the County Health
Department. This authorization may be revoked at any time by written notice of the client.

USE

This form may be used to request information from another agency or individual regarding a patient’s record, or it
may be used to authorize release of that information. For release purposes, only the minimum information
necessary to fulfill the request may be released.

The AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION (ODH Form No. 206) must have the
following information:

1.   Patient’s name, date of birth, and address.

2.   Name of the releasing agency or individual.

3.   Describe type of information being released.

4.   Name of record(s) the information is being released from,

5.   Put full name and address of person, agency or firm authorized to receive information.

6.   INFORM PATIENT OF THE STATEMENT – NOTICE (63 O.S. 1992, 1-502.2.B). This authorization is
     revoked once written notice of the revocation is received. The word “Revoked” is written across the face of
     the form and the written revocation is attached. The client may also sign and date the face of the form next to
     the word “Revoked” (written in red ink) to effect revocation.

7.   Record the valid “until” date (MM-DD-YY). This is normally twelve months or less from the date of the
     patient’s signature. Some Programs guidelines permit longer valid periods. However, the client’s wishes
     take priority.

8.   The patient, patient’s guardian, or an authorized individual signs the form. An original signature is not
     required for the health department record. (When someone other than the patient signs the release, the
     relationship to the patient should be designated. If someone other than the guardian signs the patient’s name,
     there should be a brief statement that explains why the patient did not sign the form.)

9.   Signature of Witnesses. (This might be the staff member who gets the release signed. If the patient signs by
     mark, there must be two witnesses who know the patient.)

The specific information released, to whom the information was released, the name of the OSDH employee
authorizing the release and the date released should be noted in the “FOR COUNTY HEALTH DEPARTMENT
USE” section of the file copy.

ROUTING and FILING

A signed copy of this release should be kept in the patient’s record, and a signed or duplicate copy should
accompany the information to the requesting agency or individual. When the County Health Department is
requesting information from another agency or individual regarding a patient’s record, the release with the
original signature should be sent to the other agency. The copy of the AUTHORIZATION TO RELEASE
CONFIDENTIAL INFORMATION should then be placed in the patient’s record.

                                                                                                     (REV. 11/07)

								
To top