192.521] ����� Note: See note under 192.553. ����� 192.565 [1977 c.517 �4; 1999 c.80 �30; renumbered 192.596 in 2011] ����� 192.566 Authorization form. A health care provider may use an au

192.521]

����� Note: See note under 192.553.

����� 192.565 [1977 c.517 �4; 1999 c.80 �30; renumbered 192.596 in 2011]

����� 192.566 Authorization form. A health care provider may use an authorization that contains the following provisions in accordance with ORS 192.558:

______________________________________________________________________________

AUTHORIZATION

TO USE AND DISCLOSE

PROTECTED HEALTH INFORMATION

I authorize: _______________ (Name of person/entity disclosing information) to use and disclose a copy of the specific health information described below regarding: _______________ (Name of individual) consisting of: (Describe information to be used/disclosed)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

to: _______________ (Name and address of recipient or recipients) for the purpose of: (Describe each purpose of disclosure or indicate that the disclosure is at the request of the individual)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed if I mark in the applicable space next to the type of information.

_____� HIV/AIDS information

_____� Mental health information

_____� Genetic testing information

_____� Drug/alcohol diagnosis, treatment, or

����� referral information.

I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict redisclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol diagnosis, treatment or referral information.

PROVIDER INFORMATION

You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure.

You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage.

To revoke this authorization, please send a written statement to ____________ (contact person) at ____________ (address of person/entity disclosing information) and state that you are revoking this authorization.

SIGNATURE

I have read this authorization and I understand it. Unless revoked, this authorization expires ________ (insert either applicable date or event).

By: ______________________

����� (individual or personal representative)

Date: ____________

Description of personal representative�s authority:

___________________________

______________________________________________________________________________ [Formerly 192.522; 2024 c.73 �14]

����� Note: See note under 192.553.

����� 192.567 Disclosure without authorization form. (1)(a) A health care provider may use or disclose protected health information of an individual without obtaining an authorization from the individual or a personal representative of the individual if the conditions in paragraph (b) of this subsection are met and:

����� (A) The disclosure is to a family member, other relative, a close personal friend or other person identified by the individual, and the protected health information is directly relevant to the person�s involvement with the individual�s health care; or

����� (B) The disclosure is for the purpose of notifying a family member, a personal representative of the individual or another person responsible for the care of the individual of the individual�s location, general condition or death.

����� (b) A health care provider may make the disclosures described in paragraph (a) of this subsection if:

����� (A)(i) The individual is not present or obtaining the individual�s authorization is not practicable due to the individual�s incapacity or an emergency circumstance; and

����� (ii) In the exercise of professional judgment and based on reasonable inferences, the health care provider determines that the disclosure is in the best interests of the individual; or

����� (B) The individual is present and the health care provider gives the individual an opportunity to object to the disclosure and the individual does not express an objection or the health care provider reasonably infers from the circumstances, based on the exercise of professional judgment, that the individual does not object to the disclosure.

����� (2) A health care provider may disclose protected health information to a person if the health care provider, consistent with standards of ethical conduct, believes in good faith that the disclosure is necessary to prevent or lessen a serious threat to the health or safety of any person or the public, and if the information is disclosed only to a person who is reasonably able to prevent or lessen the threat, including the target of the threat.

����� (3) With respect to an individual who is being treated for a mental illness, the protected health information disclosed under this section may include, to the extent consistent with the health care provider�s professional judgment and standards of ethical conduct:

����� (a) The individual�s diagnoses and the treatment recommendations;

����� (b) Issues concerning the safety of the individual, including risk factors for suicide, steps that can be taken to make the individual�s home safer, and a safety plan to monitor and support the individual;

����� (c) Information about resources that are available in the community to help the individual, such as case management and support groups; and

����� (d) The process to ensure that the individual safely transitions to a higher or lower level of care, including an interim safety plan.

����� (4) Any disclosure of protected health information under this section must be limited to the minimum necessary to accomplish the purpose of the disclosure.

����� (5) A health care provider is not subject to any civil liability for making a disclosure in accordance with this section.

����� (6) This section shall be known and may be cited as the Susanna Blake Gabay Act. [2015 c.473 ��2,3]

����� Note: See note under 192.553.

����� 192.568 Confidentiality; use and disclosure. A health care provider or a state health plan does not breach a confidential relationship with an individual if the health care provider or state health plan uses or discloses protected health information in accordance with ORS