Healthcare Special ROIs

HEALTHCARE SPECIAL RELEASE OF INFORMATION (SPECIAL ROI)

Patient Information

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:

Insurance Information (if applicable)

Recipient of Information

Release to (Name or Organization):

Recipient Phone:    Recipient Fax:

Specific Information to Be Released (check all that apply)

Medical records, clinical notes, diagnostic studies, progress notes
Laboratory and pathology reports
Radiology reports and images
Billing and payment records
Substance use treatment records (42 CFR Part 2) — specific authorization required
HIV/AIDS-related information — specific authorization required
Mental health records (including psychotherapy notes if checked below)
Psychotherapy notes (separate explicit authorization required)

Purpose of Disclosure and Limits

Purpose of disclosure:

Time period for records to be disclosed: From to

Method of Disclosure

Paper copies
Electronic transmission (secure portal, encrypted email) — recipient agrees to safeguard information
Verbal communication between providers

Authorization, Redisclosure & Revocation

I hereby authorize the designated provider to disclose the protected health information described above to the recipient named in this form. I understand that this authorization is voluntary and that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except where allowed by law.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws. I release the disclosing provider from any liability that may result from the release of information pursuant to this authorization.

I may revoke this authorization at any time by delivering a written revocation to the Health Information Management Department. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation. The revocation is not effective to the extent that action has been taken in reliance on this authorization.

Financial Liability and Fees

I understand that I may be charged a reasonable fee for the preparation and reproduction of records as permitted by law. If fees apply, the recipient or I will be responsible for payment as required by the disclosing provider's policy.

Expiration

This authorization expires on: . If no date is provided, this authorization will expire one year from the date signed.

Acknowledgments and Certifications

By signing below I certify that I have read and understand the terms of this authorization. I acknowledge that I have been provided the opportunity to receive a copy of this authorization. I understand the types of information to be disclosed and the potential consequences of such disclosure.

If this authorization pertains to sensitive categories of information such as HIV-related information, substance use treatment records, or psychotherapy notes, I have specifically initialed those sections above and understand additional protections may apply.

Patient Signature and Authorization

If signed by personal representative, describe authority (e.g., legal guardian, power of attorney):

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