Healthcare Case Management ROI

Healthcare Case Management Release of Information (ROI)

Patient Name:   Date of Birth:   Medical Record / ID #:

1. Patient Information

2. Insurance / Payer Information

3. Medical History (for case manager reference)

4. Recipient(s) Authorized to Receive or Release Information

Organization / Individual 1:   Phone:

Organization / Individual 2:   Phone:

5. Purpose of Disclosure

The information described below may be used or disclosed for the following purposes (check all that apply):

Case management and care coordination     Benefits assistance and eligibility     Referrals to community resources

Billing, claims, and payment coordination     Legal or administrative proceedings     Other:

6. Information to be Released

I specifically authorize the release of the following categories of information (check all that apply). Sensitive categories require explicit selection.

General medical records (diagnoses, progress notes, treatment plans)
Billing, payment, and insurance information
Laboratory results and imaging reports
Medication lists and prescription history

Sensitive information (select only if you specifically authorize release):
Mental health/psychotherapy notes
Substance use treatment records (confidential)
HIV-related information and test results

7. Authorization Period and Expiration

This authorization is effective upon signature and remains in effect until:

If no expiration is specified, this authorization will expire one year from the date of signature unless otherwise revoked in writing.

8. Right to Revoke; Effect of Refusal

I understand that I may revoke this authorization at any time by providing a written notice to the releasing organization, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures already made in reliance on this authorization.

I understand that my refusal to sign will not result in the denial of treatment, payment, enrollment, or eligibility for benefits, except when the provision of protected health information is necessary for the entity to fulfill its duties under a program or to determine eligibility, in which case denial may be permitted by law.

9. Redisclosure and Confidentiality

I understand that 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, except for information protected by specific confidentiality laws (for example, certain substance use treatment records) which require additional protections and restrictions on redisclosure.

10. Fees and Records Copy

A reasonable fee may be charged for copying and mailing records when permitted by applicable law. Information required for ongoing case management will be provided without withholding for legitimate care coordination needs, subject to applicable fee limitations.

11. Additional Authorizations

I authorize release of information by electronic means, including secure electronic transmission and fax, when deemed necessary for care coordination: Yes

12. Acknowledgment and Certification

By signing below I certify that I am the patient or the patient's legally authorized representative and that I have read and understand the terms of this authorization. I authorize the release and/or exchange of the protected health information described above for the purposes stated. I understand that I may receive a copy of this signed authorization upon request.

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