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