Authorization to Disclose Health Information
Name ________________________________________ Date of Birth______________________________
I, ______________________________________________________, hereby authorize the Ohio
Department of Health to (Client, Patient or Personal Representative)
disclose specific and identifiable health information from the records of the above-named person to
(Recipient Name/Address/Phone/Fax):
_______________________________________________________________________________________
_______________________________________________________________________________________
for the specific purpose(s) of:
_______________________________________________________________________________________
_______________________________________________________________________________________
Specific information to be disclosed:
_______________________________________________________________________________________
_______________________________________________________________________________________
This authorization will expire on the following date, event or condition:
_______________________________________________________________________________________
I understand that if I fail to specify an expiration date or condition, this authorization is valid for the
period of time n
eeded to ful
fill its purpose. I
also understand tha
t I may
revoke this autho
rization, in
writing, at any time. I further understand that any action taken by the Ohio Department of Health in
accordance to this authorization prior to it being revoked is legal and binding.
I understand that my information may not be protected from re-disclosure by the requester of the
information unless otherwise provided for by state or federal law.
I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my
ability to obtain tr
eatment,
payment for service
s, or my el
igibility for ben
efits; however, i
f a service is
requested by a non-treatment provider (e.g., insurance company) for the sole purpose of creating health
information (e.g., physical exam), service may be denied if authorization is not given.
I further understand that I may request a copy of this signed authorization.
(Signature of Client/Patient) (Date) (Witness-If Required)
**********
NOTE: This Authorization was revoked on:
(Date) (Signature of Staff)