Healthcare OhioRise ROI

OhioRise Release of Information (ROI)

Patient Information

Patient Name:    DOB:

Gender:    Phone:

Request Details

Release Direction: Release FROM OhioRise to recipient    Release TO OhioRise from another provider

Recipient Phone:    Fax:    Email:

Description of Information to Be Released

Select specific records or check "Entire Record". Psychotherapy notes require explicit initialing below to be disclosed.

Entire Medical Record    Medication List    Laboratory and Test Results

Behavioral Health / Progress Notes    Substance Use Treatment Records    HIV/AIDS Related Records

Genetic Testing Results    Psychotherapy Notes (requires initials)   Initials:

Purpose of Disclosure

Purpose (select one or specify):   Continuity of Care    Insurance/Claim    Legal

Method of Disclosure

Mail    Fax    Email (unsecure)    Secure Portal    Patient Pick-up

Authorization and Legal Notices

I authorize OhioRise and its agents to disclose the protected health information described above to the recipient named in this form. I understand that such information may include records created by other providers that OhioRise maintains.

I understand that I may revoke this authorization at any time by providing a written notice to OhioRise, except to the extent that action has already been taken in reliance on this authorization. To revoke, send a written notice to the OhioRise Privacy Office, referencing this authorization. Revocation will not affect disclosures already made.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected under federal privacy law. Certain records may be protected by state or federal law and may require additional authorization for disclosure.

I understand that OhioRise may charge a reasonable, cost-based fee for copies of medical records as permitted by law, and that payment may be required before copies are released.

My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my signing this authorization, except where permitted by law for purposes such as research-related treatment or as otherwise required.

This authorization will expire on:   Or upon the occurrence of the following event:
If no date or event is provided, this authorization will expire 90 days from the date signed.

I acknowledge that I have been offered a copy of OhioRise's Notice of Privacy Practices.    I request a copy of this signed authorization for my records.

Signature

By signing below, I certify that I am the patient or the patient’s personal representative authorized to sign on behalf of the patient, and that the information provided is accurate to the best of my knowledge. I understand the consequences of authorizing the release of the described information.

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