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Request/Release of Medical Records

Patient Information

Authorizations(Please Check All that Apply):

Requested Information

Delivery Information (Complete only the information that is applicable to your request)

Confidential Health InformationIf 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 check below.


Disclosure & Authorization Signature: 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 represent research related treatment and the authorization is necessary to participate in the research study and receive research related treatment.I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol diagnosis, treatment or referral information and specifically require my authorization prior to re-disclosure.

Expiration: This authorization is valid for 180 days from the date of authorization or until specified date unless revoked by the patient orally or in writing at an earlier time. I understand that if I am requesting information from Oregon Orthopedic & Sports Medicine, I can revoke this authorization by contacting the HIPAA Privacy Officer, 1508 Division Street, Ste 105, Oregon City, OR 97045, telephone 503-656-0836. The exception is when the action has already occurred as instructed in thisauthorization. If signing for a person over the age of 18, proof of guardianship, power of attorney, or executor of estate must be provided.

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