FAMILY TREE CLINIC ROI (RELEASE OF INFORMATION)

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

Date of Birth: *

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

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: *

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:

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 *

Date