Healthcare ROI Report

HEALTHCARE RELEASE OF INFORMATION (ROI) REPORT

Patient Information

Date of Birth:    Gender:

Phone:    Medical Record No.:

Requester / Recipient

Phone:    Fax:    Email:

Authorization Details

Authorization ID:    Date of Authorization:

Expiration Date (or event):    No Expiration (check if indefinite):

Records to be Released / Disclosed

The following records are authorized for disclosure (check all that apply):

Complete Medical Record    Discharge Summary    Imaging Reports

Laboratory Results    Billing/Account Records    Behavioral Health Records

Substance Abuse Records    HIV/AIDS-Related Records    Other:

Date Range (if applicable): From to

Legal Notices and Patient Rights

This authorization is voluntary. The facility will not condition treatment, payment, enrollment, or eligibility for benefits on whether the patient signs this authorization, except where allowed by law. The patient understands that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy law. State laws may further restrict redisclosure of certain categories of information including, but not limited to, HIV-related information, mental health records, and substance-abuse treatment records.

The patient may revoke this authorization in writing at any time by submitting a signed written notice to the facility's Release of Information department. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Disclosure of records relating to minors, substance abuse treatment, mental health treatment, and communicable diseases may be subject to additional legal protections. Where additional state or federal protections apply, such information will only be released in accordance with applicable law.

Disclosure Log (Records Released)

Use the fields below to document each instance of disclosure made pursuant to this authorization. Complete a separate line for each disclosure.

Date Disclosed:    Recipient Name:    Method:

Purpose:

Date Disclosed:    Recipient Name:    Method:

Purpose:

Date Disclosed:    Recipient Name:    Method:

Purpose:

Date Disclosed:    Recipient Name:    Method:

Purpose:

Date Disclosed:    Recipient Name:    Method:

Purpose:

Release Processing / Verification

Verification Method (ID presented, confirmation process):

Release Method:    Date Released:

Acknowledgment and Certification

By signing below, the patient or the patient's legally authorized representative certifies that this authorization is accurate and complete, that they have the authority to authorize disclosure of the information described above, and that they understand the rights and notices described in this form. The signer acknowledges receipt of a copy of this authorization upon request.

I acknowledge that I have read and understand this authorization:

Sign Now