Healthcare Crossroads ROI Form

Healthcare Crossroads Release of Information (ROI) Form

This Authorization permits Healthcare Crossroads to use or disclose the protected health information described below. Patient Name: Date of Birth: Medical Record Number (if known):

Patient Information

Insurance Information (if applicable)

Release To / From

Release Records From (Facility/Provider):

Release Records To (Recipient):

Purpose of Disclosure

Purpose (select one or more): Continuing care Insurance/Claims Legal Personal use Other:

Records to Be Released

All medical records

Records from date: to

Specific types (check all that apply):

Billing records Lab reports Imaging/radiology reports

Operative reports Discharge summaries Clinic/office notes

Immunizations Emergency department records Other:

Sensitive Information – Separate Authorization / Initials Required

Certain information is especially protected. By initialing next to an item you specifically authorize disclosure of that information.

HIV/AIDS-related records (initials required):

Substance use disorder treatment records (initials required):

Mental health/psychiatric records (initials required):

Psychotherapy notes (separate authorization required; initials required):

Format and Delivery

Delivery method (check one or more): Pick up at HealthCrossroads Mail Fax Secure electronic transmission

I understand that if the information is requested to be transmitted by unencrypted email or regular (non-secure) fax, there is a risk of unauthorized access and Healthcare Crossroads is not liable for inadvertent redisclosure after release.

Expiration, Revocation, and Fees

This authorization will expire on: . I may revoke this authorization at any time by submitting a written revocation to Healthcare Crossroads, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization.

I understand that fees for copying and postage may apply in accordance with applicable law and Healthcare Crossroads' policies. Charges will be communicated prior to release when required by law.

Redisclosure Notice

I understand that once my protected health information is disclosed to the recipient named on this form, it may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. If this authorization is for disclosure to an insurance company and the purpose is to obtain payment, I understand the insurer may further disclose the information to its agents or review organizations.

Acknowledgment of Rights

By signing below I acknowledge that I have read and understand this authorization, that signing is voluntary, and that I may request a copy of this form. I acknowledge that Healthcare Crossroads will not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization except as permitted by law.

HIPAA Privacy Notice Acknowledgement: I acknowledge that I have been offered or received a copy of the Healthcare Crossroads Notice of Privacy Practices.

If signed by a personal representative or legal guardian, complete relationship and authority below.

Certification: I certify that the information I have provided is true and accurate to the best of my knowledge and that I am authorized to request the release of the records described above.

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