Form ODM03397 "Authorization for the Release or Use of Protected Health Information" - Ohio

What Is Form ODM03397?

This is a legal form that was released by the Ohio Department of Medicaid - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2020;
  • The latest edition provided by the Ohio Department of Medicaid;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ODM03397 by clicking the link below or browse more documents and templates provided by the Ohio Department of Medicaid.

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Download Form ODM03397 "Authorization for the Release or Use of Protected Health Information" - Ohio

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Ohio Department of Medicaid
Authorization for the Release or Use of Protected Health Information
SECTION A
Name
Medicaid ID/Case Number
Address
City
State
Zip Code
I, ________________________________________, hereby authorize ________________________________________ to disclose
(Name of Individual)
(Name of covered entity, such as “ODM”)
Protected Health information to _________________________________ for the purpose of _______________________________
(Who will receive the information?)
(Statement of the purpose for this release or disclosure)
The information is to be sent to
Street
City
State
Zip Code
Section B
The specific information to be released is
SECTION C
By signing below, I understand that:
This authorization shall expire on ____________________ or until revoked by me in writing, whichever comes first.
(date or completion of "event")
I have the right to revoke or cancel this authorization at any time by providing notice in writing to the Ohio Department of
Medicaid, Attn: Health Information Privacy Official, P.O. Box 182709, Columbus, OH 43218-2709.
If I revoke or cancel this authorization, it is not effective for the use or for the disclosure of my information that has already
occurred.
Any information used or disclosed as per this specific authorization may be re-disclosed by the person or entity receiving the
information. In such a situation, it may no longer be protected from disclosure by federal or state law.
I understand that my receipt of treatment, the payment for my treatment, and my enrollment or eligibility for benefits or
services is not conditioned on signing this authorization unless the authorization is necessary for determining eligibility for
the program or enrollment in the program.
I have a right to inspect or copy the information that will be used or disclosed as per this authorization.
I understand that in the event my records contain psychotherapy notes, a separate authorization may be required for the
psychotherapy notes.
I understand that this authorization permits the use and/or disclosure of information related to HIV testing or the treatment
of AIDS or AIDS related conditions, drug or alcohol abuse, psychiatric conditions (excluding psychotherapy notes) unless
excluded in Section B.
Signature of Individual or Representative
Print Name of Individual
Date
Representative’s Authority to Act for Individual
Print Name of Representative
Date
ODM 03397 (Rev. 6/2021)
Ohio Department of Medicaid
Authorization for the Release or Use of Protected Health Information
SECTION A
Name
Medicaid ID/Case Number
Address
City
State
Zip Code
I, ________________________________________, hereby authorize ________________________________________ to disclose
(Name of Individual)
(Name of covered entity, such as “ODM”)
Protected Health information to _________________________________ for the purpose of _______________________________
(Who will receive the information?)
(Statement of the purpose for this release or disclosure)
The information is to be sent to
Street
City
State
Zip Code
Section B
The specific information to be released is
SECTION C
By signing below, I understand that:
This authorization shall expire on ____________________ or until revoked by me in writing, whichever comes first.
(date or completion of "event")
I have the right to revoke or cancel this authorization at any time by providing notice in writing to the Ohio Department of
Medicaid, Attn: Health Information Privacy Official, P.O. Box 182709, Columbus, OH 43218-2709.
If I revoke or cancel this authorization, it is not effective for the use or for the disclosure of my information that has already
occurred.
Any information used or disclosed as per this specific authorization may be re-disclosed by the person or entity receiving the
information. In such a situation, it may no longer be protected from disclosure by federal or state law.
I understand that my receipt of treatment, the payment for my treatment, and my enrollment or eligibility for benefits or
services is not conditioned on signing this authorization unless the authorization is necessary for determining eligibility for
the program or enrollment in the program.
I have a right to inspect or copy the information that will be used or disclosed as per this authorization.
I understand that in the event my records contain psychotherapy notes, a separate authorization may be required for the
psychotherapy notes.
I understand that this authorization permits the use and/or disclosure of information related to HIV testing or the treatment
of AIDS or AIDS related conditions, drug or alcohol abuse, psychiatric conditions (excluding psychotherapy notes) unless
excluded in Section B.
Signature of Individual or Representative
Print Name of Individual
Date
Representative’s Authority to Act for Individual
Print Name of Representative
Date
ODM 03397 (Rev. 6/2021)