ROI forms
Federal law (HIPAA) requires health service providers to obtain written permission from patients to release protected health information to a third party. This includes permission to release of written records as well as permission to verbally disclose information. The Corvallis Clinic has 2 release of information forms, one for each purpose:
Please download and print the appropriate forms, complete them, and return them to me using using the instructions at this link. If you don't have a printer, please call us (at 541-754-1288) and we can mail the form to you. Also, please call us if you have questions about the forms.
Advice about completing the forms
Section 1 asks about the "purpose of release request." Typically, this will be "Doctor consultation/referral." If it is for another reason, please specify (e.g., for FMLA).
Section 2 asks about the "Type of General Medical Information to be Released." Typically, the answer here is "Specialty Behavioral Health Department records." If the purpose of the release is to communicate with a physician outside of The Corvallis Clinic, check the box by "Physician notes and records (limited to two (2) years of information and mental health and mental health diagnosis)."
For section 3, check the box for The Corvallis Clinic, P.C.
For section 4, enter the name and contact information for the person or facility you want me to release information to.
For section 5, I recommend specifying a date one year from the date you sign the form.
How to return the forms to me
Please use the instructions at this link.