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Community Vendors ROI

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Authorization to Use and Disclose Protected Health Information

(Name of individual for whom records or information is to be disclosed) (Date of Birth)

Authorized Entity: Community Vendors

Information to be Disclosed:

Support Specialist's affiliation with Center for Family Development

The purpose of this disclosure:

To receive a discount, as applicable

No information in the areas listed below will be included:

Mental health information

Drug/alcohol diagnosis, treatment, or referral information

HIV/AIDS information

Genetic testing information

I understand that my records are protected by State Law (ORS 192.553-192.581, ORS 179.505) and Federal privacy regulations in the Health Insurance Portability and Accountability Act (HIPAA), 45 CFR Parts 160 & 164. I understand that the information specified above will be disclosed based on this authorization.

For individuals involved in CFD’s Recovery Program, confidentiality of this record is protected by Federal Law 42 CFR Part 2. Any information that identifies an individual as involved in the Recovery Program cannot be disclosed without written consent except in limited circumstances as specified in these regulations. Federal Law 42 CFR Part 2 prohibits unauthorized disclosure of Recovery Program records.

I understand that CFD has no control over possible re-disclosure of the information by the receiving agency or individual. I understand that CFD may not condition services, payment, enrollment in the health plan, or eligibility for benefits on whether I sign this Authorization.

I understand that this Authorization may be revoked in writing at any time, except to the extent that action has been taken prior to revoking it. Should I decide to revoke this Authorization prior to its expiration, I understand that I must do so in writing by submitting notification to my therapist or to the CFD Records Custodian. Unless revoked, this Authorization shall remain in effect until 90 (ninety) days following service conclusion.

I understand that my signature below authorizes a disclosure of information and records between the above designated parties.

This document is being signed by: ClientPersonal Representative

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

July 28, 2023 9:13 am PDT

Community Vendors ROI Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.1

July 28, 2023 9:32 am PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.7

June 5, 2024 2:44 pm PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.1