FAMILY TREE CLINIC ROI (RELEASE OF INFORMATION)

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION
Date of Birth: *

Month Day Year
Date
Legal Name *

Legal Last Name First Name
Preferred Name:
Social Security #
Address:
City:
State:
Zip:
Clinic/Hospital/Health Care Provider (Who has the information you want released? Please list the specific clinic or provider.)
Provider Name: *
Name of Clinic or Hospital (Who has the information you want released? Please list the specific clinic or provider.) *
Address:
City:
State:
Zip:
Phone: *
Fax:
Receiving Party (Where do you want the information sent? Who may have the information? If you are releasing information to yourself, please list "self".)
Name: *
Address
City:
State:
Zip:
Phone:
Fax:
Information to be Released (What do you want sent or released? Check the appropriate box.)
Please indicate date(s) of service:
Visit notes Hormone related care Hospital STI results Pap smear / colposcopy / pathology
Initial to include HIV results in STI results

Clear
Any and all records

Any and all records
Initial to include HIV results with "Any and all records"

Clear
Only records types checked below:

Laboratory reports Emergency records Medication records Immunization records Ok to discuss protected health information (no records needed unless indicated above) Imaging reports
Chemical dependency results
Initial for chemical dependency results

Clear
Mental health results
Initial for mental health results

Clear
HIV test results
Initial for HIV results

Clear
Release Instructions
Date information is needed: *

Month Day Year
Date
Purpose of Release *

Continuing care Personal use or review Insurance payment/claim Transfer of care Legal
Receive records by: *

Mail Pick up Fax
This authorization lasts for one year unless otherwise requested. I would like my authorization to expire 14 days after the following date:

Month Day Year
Date
- You may cancel this authorization at any time by writing to Family Tree Clinic. A cancellation will not change releases that happen before the cancellation
- A photocopy/fax of this authorization will be treated in the same way as an original.
- Family Tree Clinic may include records that it received from other organizations. If these records have been used by Family Tree Clinic and filed in the record Family Tree Clinic maintains about you, these records may be released with your Family Tree Clinic records.
- Family Tree Clinic cannot prevent redisclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release Family Tree Clinic from any and all liability resulting from a redisclosure by the recipient.
- Family Tree Clinic will not condition treatment, payment, enrollment or eligibility for benefits on whether or not you sign this form.
- Your signature indicates that you have read and understand this form, and authorize release of your information as described above
Patient/Legal Guardian Signature *

Clear
Today's date *

Month Day Year
Date
Should be Empty:

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