OHSU Privacy and Security Forms

The following privacy and security 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.

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. The form is also available in Chinese, Russian, Spanish and Vietnamese.

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

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.

Right to an 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.