Authorization to Disclose Health Information
Name ________________________________________ Date of Birth______________________________
I, ______________________________________________________, hereby authorize the Ohio
Department of Health to (Client, Patient or Personal Representative)
disclose specific and identifiable health information from the records of the above-named person to
(Recipient Name/Address/Phone/Fax):
_______________________________________________________________________________________
_______________________________________________________________________________________
for the specific purpose(s) of:
_______________________________________________________________________________________
_______________________________________________________________________________________
Specific information to be disclosed:
_______________________________________________________________________________________
_______________________________________________________________________________________
This authorization will expire on the following date, event or condition:
_______________________________________________________________________________________
I understand that if I fail to specify an expiration date or condition, this authorization is valid for the
period of time needed to fulfill its purpose. I also understand that I may revoke this authorization, in
writing, at any time. I further understand that any action taken by the Ohio Department of Health in
accordance to this authorization prior to it being revoked is legal and binding.
I understand that my information may not be protected from re-disclosure by the requester of the
information unless otherwise provided for by state or federal law.
I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my
ability to obtain treatment, payment for services, or my eligibility for benefits; however, if a service is
requested by a non-treatment provider (e.g., insurance company) for the sole purpose of creating health
information (e.g., physical exam), service may be denied if authorization is not given.
I further understand that I may request a copy of this signed authorization.
(Signature of Client/Patient) (Date) (Witness-If Required)
(Signature of Personal Representative) (Date) (Relationship/Authority)
**********
NOTE: This Authorization was revoked on:
(Date) (Signature of Staff)