Authorization to Release Health Information/Treatment Records

Patient Last Name: First: Middle:

Other Names Used: Birthdate:

Address: City: State: Zip:

Home Phone: ( ) Alt. Phone: ( ) Cell Phone: ( )

If currently enrolled OU student, enrollment dates: to

 I request that the health information (or, if I am a student, my treatment/education record) checked below from, (date)_____________ to (date)
________________ maintained or created by the Provider named below be released to the Recipient named below.
 Initial here if information from your records may also be disclosed verbally to the recipient below:____________

Purpose of Request: referral legal transfer other:____________________________________________________________

The records I request access to or a copy of are:

OR only these portions of my record:

Entire Health Record*
Excludes Billing Records/Notes and Psychotherapy

X-ray Reports/Films Immunization Records Medications Orders

Discharge Summaries Admission Form Intake/Outtake Cath lab

Entire Health Record plus Billing Records/Notes*
Excludes Psychotherapy Notes*
Operative Info Pathology/Lab Reports Dictation reports Tests

Psychotherapy Notes* (if checking this box, no other boxes may be ER information All Billing Records UB-04 Itemized bill
checked. A separate copy of this form must be completed to obtain Other: ________________________________________________________
any other types of records.)
*The information authorized for release may include information related to mental health. Release of mental health records or psychotherapy notes
may require consent of the treating provider or a court order.

Covered Entity Authorized to Release Records (check all that apply):

OU Health (inpatient clinics, emergency room, OU Health Physicians OKC outpatient clinics) - OU Health University of Oklahoma Medical
Center, OU Medical Center Edmond, OU Health Stephenson Cancer Center, Oklahoma Children’s Hospital OU Health, Breast Health Network, OU
Health Physicians Oklahoma City, OU Health Harold Hamm Diabetes Center, OU Health ER + Urgent Care Czech Hall Road
University of Oklahoma Health Sciences Center (University outpatient clinics, OU Health Physicians Tulsa outpatient clinics) –OU Health
Physicians Tulsa, John W. Keys Speech and Hearing Center, OUHSC College of Dentistry Clinics, OUHSC College of Pharmacy

Provide Records To Recipient:

Me Other

Name:

Address:

City: State: Zip:

© 05/2022 File in Patient Chart HIPAA Document

Retain for a minimum of 6 years
Fax: Phone:

I understand:
 I may revoke this Authorization at any time by providing my written revocation to the address at the bottom of this form or as provided in the Notice of
Privacy Practices. My revocation will not apply to information already retained, used, or disclosed under this Authorization. Unless sooner revoked,
the automatic expiration date of this Authorization will be ________ months from the date of signature (12 months, if none entered).

 Unless the purpose of this Authorization is to determine payment of a claim or benefits, OU Health may not condition the provision of treatment or
payment for my care on my signing this Authorization.

 Information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy law.
Student treatment/education records may retain continuing privacy protections in accordance with 34 CFR Part 99 (FERPA).

 The information authorized for release may include substance use disorder records. This category of medical information/records is protected by
Federal confidentiality rules (42 CFR Part 2). A general authorization for the release of medical or other information is not sufficient for this purpose.
As a result, by signing below, I specifically authorize any such records included in my health information to be released. The Federal rules restrict any
use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. The Federal rules prohibit anyone receiving this
information or record from making further release unless further release is expressly permitted by the written authorization of the person to whom it
pertains or is otherwise permitted by 42 CFR Part 2.

 Fees may be charted in accordance with Oklahoma Statue 76 Okla. Stat. § 19 and Federal Rule 45 C.F.R. §164.524. I agree that costs for records
may be required prior to the release of the records.

Recipient will pick up copies of my records when called Mail copies of my records to the Recipient address above
Fax my records to the Recipient : (____) ___________________ Other (if available): _________________________________

I understand the security of email cannot be guaranteed and that unauthorized individuals may be able to access the message. I understand the information
sent via electronic communication may include information that may indicate the presence of a communicable disease or non-communicable disease, mental
health records, or substance use disorder records. It is my responsibility to notify OU if the email address information changes after submitting this form. I
understand and agree to the statements above and wish to have my records sent to the Recipient
via email at: ___________________________________________@_____________________.

Signature of Patient, Parent, or Authorized Legal Representative** Relationship to Patient Date

**May be requested to show proof of representative status

OU Health, HIM, 1200 Children’s Ave. Suite B300, Oklahoma City, OK 73104 (405) 271-6892, (405)271-3072 fax [email protected]
University of Oklahoma Health Sciences Center, University Privacy Official, PO Box 26901, Oklahoma City, OK 73129 (405) 271-2511 [email protected]

© 05/2022 File in Patient Chart HIPAA Document

Retain for a minimum of 6 years