Healthcare ACE ROI Form

HEALTHCARE ACE RELEASE OF INFORMATION AUTHORIZATION

Patient Information

Date of Birth:

Emergency Contact

Insurance Information

Medical History (brief)

Authorization to Release Information

I authorize the disclosure of confidential health information described below from: to:

Treatment / Care coordination    Billing / Claims    Legal    Personal use    Other:

ACE (Adverse Childhood Experiences) screening results
Entire medical record (excluding sensitive info unless specifically authorized below)
Behavioral health / mental health records
Substance use treatment records
HIV/AIDS-related information
Genetic testing/results
Laboratory and imaging reports
Billing and payment records
Other (specify):

Date Range of Records

From:     To:

Authorization Term / Expiration

This authorization will expire on:   or upon the earlier occurrence of the following event:

Sensitive Information — Initial to Authorize

Certain types of information are protected by additional laws. Initial each line to specifically authorize release of that information:

ACE screening data and associated psychosocial assessments: Initial

Behavioral health / psychotherapy notes: Initial

Substance use treatment records (if applicable): Initial

HIV-related information: Initial

Fees and Payment

I understand that a reasonable fee may be charged for copying and mailing records, and I agree to pay such fees unless waived. I understand that this authorization does not obligate any party to release records until fees are paid if applicable.

Revocation and Redisclosure

I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it. Revocation shall be sent to the disclosing entity identified above. Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws.

Patient Rights and Acknowledgments

I understand that: (1) my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization, except when necessary to determine payment for health care provided by research-related treatment; (2) I have the right to inspect or copy the information to be used or disclosed; and (3) I have received a copy of this signed authorization upon request.

Additional Instructions / Limits on Disclosure

Verification of Identity

To prevent improper disclosures, I certify that I am the individual named above (or legally authorized representative) and that the information below accurately identifies me.

Certification

By signing below I certify that I have read and understand this authorization. I authorize the release of the information specified above and understand the conditions under which it is released. I acknowledge that I have had the opportunity to ask questions and that my questions were answered to my satisfaction.

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