Polygrapher 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)

Agency authorized to exchange information with:

Authorized Agency or Individual Name:    Rebecca Martin, Licensed Polygraph Examiner
                                                                        541 Willamette Street, Suite 101, Eugene, OR 97401

Phone/Fax:                                                    (541) 729-1729

Information to be Disclosed:
I authorize Center for Family Development to release the following information from my records. Please initial those that apply:

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

The purpose of this disclosure is to coordinate services.

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:

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:

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Signature Certificate
Document name: Polygrapher ROI
lock iconUnique Document ID: bb323e9cedfaa357f5be1075dc711cc7a4786e3c
Timestamp Audit
December 31, 2020 2:27 pm PDTPolygrapher ROI Uploaded by Do Not Reply - donotreply@c-f-d.org IP
February 22, 2021 9:11 am PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip:
March 18, 2021 2:57 pm PDT Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:57:14 -
March 18, 2021 2:57 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip:
May 3, 2021 8:46 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: