Healthcare School ROI Form

HEALTHCARE SCHOOL RELEASE OF INFORMATION (ROI) FORM

Patient / Student Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Release Direction

Release FROM (Provider/Facility):

Release TO (School / Educational Agency):

Records to Be Released

Select records to be released (check all that apply):

Immunization records
Office visit notes / Progress notes
Behavioral health / Mental health records
Medication list / Prescriptions
Laboratory reports
Imaging / Radiology reports
Other (describe below)

Purpose of Disclosure

Method of Delivery

Mail   Fax   Email   Secure portal   In-person pickup

Sensitive Information

Sensitive categories (check to authorize). NOTE: Special state or federal rules may require separate authorization for some categories; by initialing you affirm your informed consent to release these categories.

Mental health records    Initials:

Substance use treatment records    Initials:

HIV / infectious disease records    Initials:

Genetic testing / counseling records    Initials:

Authorization Terms and Legal Notices

I hereby authorize the release of the health information described above from the Release FROM provider to the Release TO school named in this form. This authorization includes medical information created before the date of this authorization and, if indicated above, sensitive categories initialed by me. The disclosure authorized herein may include information created prior to the date of signature, unless otherwise specified above.

I understand that the information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. The Release FROM provider and its employees are released from any legal responsibility or liability for disclosure of the information identified above to the extent indicated and authorized herein.

I understand I may revoke this authorization at any time by providing a written notice of revocation to the Release FROM provider, 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 I am entitled to receive a copy of this signed authorization upon request. I understand that refusal to sign this form will not affect the individual’s ability to obtain treatment, payment, enrollment, or eligibility for benefits unless allowed by law.

If no expiration date is specified, this authorization will expire one year from the date of signature.

I agree to pay reasonable fees for copying, postage and preparation of records as permitted by law. I agree to pay applicable fees.

By signing below I acknowledge that I have read and understand the terms of this Release of Information, that I am the patient or the parent/legal guardian or authorized representative, and that I authorize the release as indicated above.

I acknowledge receipt of the facility's privacy practices and understand my rights under federal and state privacy laws.

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