OSU UNIVERSITY HEALTH SERVICES
Stillwater, OK  74078-2036  405-744-7665  Fax:  405-744-6556
This form authorizes UHS to use or disclose the personal health information listed below for the purposes stated below.
I HEREBY AUTHORIZE:                   
                         
Address City State Zip Phone/Fax
 
THESE RECORDS ARE TO BE RELEASED TO:              
                         
Address City State Zip
                         
Phone Fax
For what purpose:                    
 
*  I understand this information may be transmitted by fax if necessary for urgent medical care.
THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE INFORMATION WHICH MAY INDICATE THE PRESENCE OF A COMMUNICABLE,
NON-COMMUNICABLE, OR VENEREAL DISEASE WHICH MAY INCLUDE, BUT IS NOT LIMITED TO, DISEASE SUCH AS HEPATITIS, SYPHILIS, 
GONORRHEA AND HUMAN IMMUNODEFICIENCY VIRUS ALSO KNOWN AS ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS).  
I also understand that I may revoke (in writing) this consent at any time except to the extent that action has been taken in reliance 
on and I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest 
a claim under my policy.  In any event this consent expires automatically as described below.  SPECIFICATION OF THE DATE, EVENT OR CONDITION
UPON WHICH THIS CONSENT EXPIRES _______________________________  (If left blank this consent expires six months from date of siganture).
Personal Health Information to be used or disclosed:
  Progress Reports; _________ Lab, EKG, and/or X-ray films/reports; _________ Billing Information;
  Other ________________________________________________________ RX Information _______________
  Entire record of care provided by this offices health care professionals exclusive of the four items below.  If 
you wish any of these 4 items transferred, you must initial.
            Include           Include
AIDS or AIDS(HIV) antibody test results   Alcohol or substance abuse or treatment  
Records from other provider offices     Psychiatric/mental health diagnosis or   
    (This will include everything transferred to us.)   treatment        
 
I understand that once disclosed this information may be redisclosed by the recipient who might not be subject to HIPAA
regulations, which means the information may no longer be protected.  More information regarding your privacy rights is found
in the UHS Notice of Privacy Practices.  I understand that UHS does not condition treatment upon my willingness to sign
this authoriztion.  If the person requesting this authorization for use of PHI is NOT the individual, please state the authority
under which this request is being made:_________________________________________________________________
                         
Signature of Patient (or if under 18 years of age, Parent, Legal Guardian, Legal Representative) Date
                       
Printed Name I.D. #
                       
Address Date of Birth
                       
City, State, Zip Phone Number
 
Clinic Use Only
RELEASED BY:             DATE