Healthcare Patient Consent ROI

HEALTHCARE PATIENT CONSENT — RELEASE OF INFORMATION (ROI)

Patient Information

Patient Name:

Insurance Information

Recipient / To Whom Records May Be Released

Purpose of Disclosure

The purpose for which the information may be used or disclosed (select all that apply):

Continuity of care / treatment coordination
Insurance / reimbursement
Legal / administrative
Personal use by patient
Other — specify below

Types of Information to Be Released

Check all categories of records you authorize for release. For certain sensitive categories, initialing the corresponding box affirms specific consent.

Complete medical records (clinic notes, consultations)
Billing and payment records
Laboratory and diagnostic test reports
Radiology images and reports
Mental health / psychotherapy notes — initial to authorize:
HIV / AIDS-related information — initial to authorize:
Substance use treatment records — initial to authorize:
Genetic testing results — initial to authorize:
Other — specify below

Form of Disclosure

Records may be disclosed in the following manner (select all that apply):

Paper records mailed
Fax transmission
Secure electronic delivery
Patient or patient representative pickup
Other — specify below

Authorization Term and Revocation

This authorization expires on: . If no date is provided, this authorization expires one year from the date of signature unless a shorter period is required by law.

I understand that I may revoke this authorization at any time by delivering a written revocation to the releasing facility's Privacy Officer. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Redisclosure and Legal Notices

I understand that once my protected health information is disclosed to the recipient, federal privacy protections may no longer apply and the information may be subject to redisclosure by the recipient. The recipient may be prohibited from redisclosing substance use treatment records, HIV-related information, and certain mental health records without my specific authorization unless permitted by law. This authorization is voluntary and is not a condition of treatment, payment, enrollment, or eligibility for benefits.

Fees and Costs

I acknowledge that the releasing facility may charge a reasonable fee for copying, postage, and administrative costs associated with preparing records for release, in accordance with applicable law. If I request expedited or special handling, additional charges may apply.

Medical History Summary (Optional)

Acknowledgment and Certification

By signing below, I certify that I have read and understand this authorization. I authorize the release of the specified health information to the named recipient for the stated purpose. I understand my rights regarding revocation, the potential for redisclosure, and that this authorization is voluntary. I further certify that I am the patient or am authorized to act on behalf of the patient and that the information provided on this form is accurate.

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