Oneida Nation | Authorization for Exchange of Protected Health Information (PHI)

Name

First Name

Middle Initial

Last Name

D.O.B.

Phone

Purpose of Disclosure

I voluntarily authorize and request disclosure of this health information (including oral, paper, and electronic interchange). I have the right to refuse to sign this form. OBH will not condition treatment, payment, enrollment or eligibility in a health care plan based on my decision to sign this disclosure. If I voluntarily refuse to sign this form, the information may NOT be released. A photocopy or facsimile (fax) of this Disclosure Form is as valid as the original.

To Mutually Exchange with Oneida Behavioral Health | Address: 2640 W. Point Rd. Green Bay, WI 54304 | Phone: (920) 490-3790 | Fax: (920) 490-3883

Authorization is for DISCLOSURE ONLY

Address

City

State

Zip

Phone

Fax

*A statement that the consent is subject to revocation at any time except to the extent that the part 2 program or other lawful holder of patient identifying information that is permitted to make the disclosure has already acted in reliance on it.
Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third-party payer.

* Federal and Wisconsin Confidentiality laws protect this information. Such laws prohibit the re-disclosure of such information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by such laws.

*I understand that the information disclosed may potentially be re-disclosed by the recipient and may no longer be protected by the Federal Privacy and Confidentiality rules.

*I understand that I have the right to revoke this authorization at any time.
I understand that if I revoke this authorization, I must do so by submitting my revocation in writing to the Oneida Behavioral Health Medical Records Department.
My revocation will not apply to confidential information that has already been released in response to this or another Disclosure form.

Information to be Used/Disclosed

Timeframe:

From:

If left blank, only last 2 years will be disclosed

To:

Check all that apply

*Psychotherapy Notes is selected. This Release can only be used for this purpose.
A separate form must be used for the disclosure of any other information.

Authorized Person to Pick Up

Other than name listed above

Name

First Name

Last Name

Relationship to Patient

Information will be Disclosed By

Fax

U.S. Mail

Pick-Up

*I authorize use of a facsimile (fax) machine in disclosing this information.
* All Oneida Behavioral Health employees and attending physicians are released from legal responsibility or liability for the release of information as indicated on this form.
If I have questions about the disclosure of my health information, I can contact, Privacy Official, at (920) 869-2711.
* All of Oneida Behavioral Health Services respect the patient’s right to privacy of confidential medical information.
I have had an opportunity to review and understand the content of this Disclosure form.
I understand that I may inspect or receive a copy of the information to be used or disclosed.

Expiration Date:

This Authorization is good until the following date or event:

If left blank authorization will expire in ONE YEAR FROM the date signed below.

Signature

Clear

Date

Parent/Legal Representative: I declare that I am the above named minor child’s parent and I represent I have not been denied access to this child by a court of law and/or denied periods of physical placement with the child.

Legal Guardian (Proof of Guardianship Received)

Other (Please Specify)Other (Please Specify)

Witness

Date

Relationship

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of Behavioral Health or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
* Provision of research-related treatment or treatment that is for the sole purpose of creating health information for disclosure to a third party will not be provided without your written authorization.