Free To Compel the Production of Individually Identifiable Health Information - Oregon

Workers' Compensation Board State of Oregon
In the Matter of the Request for Hearing of ) WCB Case No. ) ) SUBPOENA ) To Compel the Production of ) Individually ) Identifiable Health Information1

To:

YOU ARE DIRECTED to copy and send documents, including Individually Identifiable Health Information, concerning the following individual:
Claimant's Name Claim No.

WCB Case No.

Documents to be sent:

Send Documents to:

Date

Issuer

[ Continued ]
"Individually Identifiable Health Information" is: information which identifies an individual or which could be used to identify an individual, which has been collected from an individual and created or received by a health care provider, health plan, employer or health care clearinghouse; and which relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual.
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I certify that I delivered a copy of this subpoena to
(Custodian of records being subpoenaed)

at
(Address)

on
(Date)

by personal delivery or by certified mail return receipt requested. I also certify that I mailed a copy of this subpoena to
(Individual or attorney of individual whose records are being subpoenaed)

at
(Address)

on
(Date)

By certified mail return receipt requested.

Signature

Date

NOTICE
TO INDIVIDUAL WHOSE INDIVIDUALLY IDENTIFIABLE HEALTH RECORDS ARE BEING SUBPOENAED IF YOU OPPOSE THE DISCLOSURE OF THE INFORMATION INCLUDED IN THIS SUBPOENA, YOU MUST FILE A WRITTEN OBJECTION WITH THE WORKERS' COMPENSATION BOARD, 2601 25TH STREET SE., SUITE 150, SALEM, OREGON 97302-1280. YOUR OBJECTION MUST BE FILED WITHIN SEVEN (7) CALENDAR DAYS OF THE MAILING DATE OF THIS NOTICE, AND MUST STATE THAT YOU OBJECT TO THE RELEASE OF THE INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION, THE BASIS FOR YOUR OBJECTION, YOUR ADDRESS, AND THE DATE OF YOUR INJURY IF YOU KNOW THE DATE. A COPY OF YOUR LETTER MUST ALSO BE PROVIDED SIMULTANEOUSLY TO THE RECIPIENT OF THE SUBPOENA, AS WELL AS TO THE PARTY ISSUING THE SUBPOENA. IF YOU HAVE QUESTIONS YOU MAY CALL THE WORKERS' COMPENSATION BOARD TOLL-FREE IN OREGON 1-877311-8061 OR, IN SALEM OR FROM OUTSIDE OREGON AT (503) 378-3308, OR THE OMBUDSMAN'S OFFICE AT (503) 378-3351, OR TOLL-FREE (800) 927-1271. NOTICE TO RECEIPIENT OF SUBPOENA: IF YOU RECEIVE A TIMELY OBJECTION FROM THE PARTY WHOSE INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION IS BEING SUBPOENAED, YOU SHALL COMPLY WITH THE SUBPOENA BY MAILING THE INFORMATION SOUGHT TO THE WORKERS' COMPENSATION BOARD AT 2601 25TH STREET, SE, SUITE 150, SALEM, OREGON 97302-1280.

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