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Access Forms Listing
Request an Appointment
Request My Medical Records
Request My X-Rays
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Request My Medical Records
Request/Release of Medical Records
Date Information Requested:
Request is being made:
At the request of the patient
At the request of the recipient
Other Names Used (if applicable)
Patient Date of Birth
Last 4 digits of SSN
Daytime Phone #(area code required)*This number will be used to contact when records are ready.
Name of person completing request
Relationship to patient
Purpose for Request
- Choose one -
copy for patient
transition of care
Authorizations(Please Check All that Apply):
I authorize the designated records to be released to OOSMC
Mail records to address indicated below
I will pick up the records in person. Please contact me when records are ready.
I authorize and request the person mentioned below to pick up the records.
I request and give permission for records to be sent electronically via fax or email.
Data Requested from Date
X-Ray and Imaging Reports
Mental Health Treatment
Drug and Alcohol Treatment
Delivery Information (Complete only the information that is applicable to your request)
Office/Facility from which records will be requested FROM
Email Address (if you wish records to be emailed)
Fax Number (if you wish records to be faxed)
Address to which records will be mailed to
Name of person picking up records, if other than the patient. (Must show photo i.d.)
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.
Confidential Health Information
HIV test, test results, and related informationincluding high risk behavior documentation
Drug/Alcohol diagnosis, treatment or referral information
Mental Health treatment information
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.
Specific Date of Expiration (if desired):
I agree to the terms and conditions outlined above and authorize the records designated above to be released as stated by my selections.
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User ID or Email
Your Caps Lock key is on
I forgot my password.