PacificSource CCO ROI
(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: PacificSource Community Solutions PO Box 7068, Springfield OR 97475-0068
Phone/Fax: (503) 210-2515
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
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
If you have questions about the contents of this document, you can email the document owner.
Document Name: PacificSource CCO ROI
Agree & Sign