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DMV 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)

I authorize an exchange of information between Center for Family Development (CFD) and the entity listed below.

Authorized Entity: Driver and Motor Vehicle Services (DMV) – Driver Suspension Unit
1905 Lana Avenue NE, Salem OR 97314

Phone/Fax: (541) 686-7855

Information to be Disclosed:
CFD may release the following information from my records, unless restricted below. Please initial those that apply:

Mental health information
Drug/alcohol diagnosis, treatment, or referral information
HIV/AIDS information
Genetic testing information

Restrictions (optional):

Include ONLY the following information:

The purpose of this disclosure is to:

Coordinate services Fulfill individual’s/guardian’s request Other:

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, see below

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

April 21, 2020 9:50 am PDT

DMV ROI Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202

April 29, 2020 8:20 am PDT

Records Department - records@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

April 29, 2020 9:31 am PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

May 5, 2020 9:36 am PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 173.8.200.225

June 24, 2020 9:34 am PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

March 18, 2021 2:21 pm PDT

Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:21:06 - 65.157.96.202

March 18, 2021 2:21 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: 65.157.96.202

May 3, 2021 10:31 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: 65.157.96.202

July 19, 2022 12:58 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: 65.157.96.202

July 20, 2022 3:37 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: 65.157.96.202