PHI Release

PROTECTED HEALTH INFORMATION RELEASE FORM
Authorization for communication of Protected Health Information to Family Members and Friends
PATIENT NAME
PATIENT'S DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I authorize the provider checked below to discuss/share protected health information about me with the following individual(s) who are involved in my care:
Provider Name:

List of Recipients

Rows	Name	Relation	Phone No.
1.
2.
3.

Type of information to be shared or disclosed:
This authorization shall remain in effect until revoked in writing by the patient. Submitting a new form will revoke existing form.
SIGNATURE
PATIENT/AUTHORIZED INDIVIDUAL
Print Name
MonthDayYear
2 digit month, 2 digit day, 4 digit year
5909 SE Division Street, Portland, OR 97206

Office 503-234-1531 Fax 503-234-2367
Should be Empty: