OHSU HIPAA and Privacy Forms

The following HIPAA and privacy forms are for use by patients seeking care at OHSU and outside organizations working with OHSU.

Authorization to Use and Disclose Protected Health Information (Form)
Use this form to authorize OHSU to release your medical records to a person(s) or entity. This form is also available in Spanish.

Authorization to Use and Disclose Protected Health Information in OHSU MyChart
The Authorization form allows OHSU to provide to another person that you designate access to health information about you through the MyChart service.

Notice of Right to Decline Future Sample Research (Form)
Use this notice and form to opt-out of Future Tissue Research and Anonymous and/or Coded Genetic Research.

Request for Amendment of Health Information (Form)
Use this form to request an amendment of your Protected Health Information.

Request to Inspect or Obtain a Copy of Own Health Information
With some exceptions, you have the right to inspect and get a copy of the health information that we use to make decisions about your care.

Request for Restriction on Use and Disclosure of Health Information (Form)
Use this form to request a restriction on the use and disclosure of your Protected Health Information.

Request for Restriction on Use and Disclosure to a Health Plan (Form)
Use this form to request a restriction on the use and disclosure of your Protected Health Information to a Health Plan.

Request for Specified Method of Communication (Form)
Use this form to request a method of communication outside of our standard communication.

Request for Accounting of Disclosures of Health Information (Form)
Use this form to request an Accounting of Disclosure of your Protected Health Information.

Temporary Suspension of an Individual's Accounting request (Form)
Use this form to suspend a patient's access to an Accounting of Disclosure of their Protected Health Information.

Information Technology Group