Healthcare ROI for Provider

HEALTHCARE RELEASE OF INFORMATION (ROI) FOR PROVIDER

Patient Information

Date of Birth:   Gender:

Primary Phone:   Email:

Medical Record Number:   Patient ID:

Recipient / Provider to Receive Records

Contact Person:   Phone:

Fax:   Email:

Authorization Details

I authorize the following provider/facility to release my protected health information:   to:

Purpose of Disclosure (check all that apply):

Treatment    Payment / Claims    Insurance    Legal    Personal Use    Other

Dates of Service to be Released: From  To   Or Release entire medical record

Types of Information to be Released (check all that apply):

Admission / Discharge Summaries
Laboratory Reports
Radiology Reports / Images
Operative Reports
Progress / Clinic Notes
Billing and Payment Records
Mental Health Records (excluding psychotherapy notes)
Psychotherapy Notes (requires separate, explicit authorization)
HIV/AIDS-related Information (requires explicit authorization)
Substance Use Disorder Treatment Records (protected; explicit authorization required)
Genetic Testing Results
Other (specify below)

Method of Release / Delivery

Mail to recipient address
Patient or authorized representative will pick up
Fax   Fax Number:
Secure Email   Email:
Electronic Portal / CD / Other Electronic Media

Fees, Expiration, Revocation and Redisclosure

I understand I may be charged a reasonable fee for copying and postage as permitted by law. I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on this authorization. To revoke, send written notice to the releasing facility's medical records department. This authorization will expire on:   If left blank, this authorization will expire one year from the date of signature.

I understand that once the information is disclosed pursuant to this authorization, the information may be subject to re-disclosure by the recipient and no longer protected by the privacy rules governing the original holder of the records. Special protections apply to substance use disorder records and certain behavioral health records; such records may require additional protections and may not be re-disclosed without further authorization except as permitted by law.

Certification and Acknowledgment

By signing below I certify that I am the patient or am authorized to act on behalf of the patient. I authorize the release of the protected health information described above. I understand that I may inspect or copy the information to be used or disclosed as provided by law.

If signed by a personal representative, the representative certifies that they have legal authority to act on behalf of the patient and must provide documentation upon request (for example, power of attorney, guardianship papers, or other legal documentation).

Sign Now