Release of Information- ROI

Patient Authorization for Disclosure of Protected Health Information (Release of Information- ROI)*

*Please note that ROIs require 7 days to process
Patient Information
Client Name*

First NameLast Name
Client Date of Birth*
MM/DD/YYYY
Client Phone Number
Please enter a valid phone number.
Program Information

Anishinaabe Endaad

3529 Zenith Ave. N

Robbinsdale, MN 55422

Main Phone: (612) 208-6613

Fax: (763) 453-7584
If applicable, please enter the name of the Hospital/Clinic/Facility that you would like Anishinaabe Endaad to exchange information with:
Agency or Person To Share Information With
Who would you like us to share or receive information with?*

Person or IndividualAgency
Person or Individual's Name
Person's relationship to you
Agency
Agency Contact (if applicable)

First NameLast Name
Agency Contact, if applicable

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
I authorize the following with the agency or person listed above:*

Sending Medical Records or Health Information to this person or organizationReceiving Medical Records or Health Information from this person or organizationSend & Receive Medical Records or Health Information from this person or organization
Information with the agency or person listed above is for the purpose of:*

Housing CoordinationCare CoordinationTransfer of CareMedical CareMutual Exchange (verbal/electronic)Patient AccessInsuranceOther
PLEASE INDICATE THE INFORMATION TO BE DISCLOSED:*

Housing Focused Person Centered PlanProfessional Statement of Need (PSN)Entire recordProblem list, med list, Last office visitEmergency dept. report(s)Discharge summaryHistory and physicalLaboratory report(s)Pathology report(s)Radiology report(s)Consultation report(s)Neuropsych/Development TestBehavioral Health record(s)Immunization HistoryProgress report(s)Verbal/electronic exchange of case file informationEmergency contactTransfer of property if client unable upon dischargeOther
DISCLOSURES/SPECIAL CONSENT: In compliance with Minnesota Statutes which require special permission to disclose otherwise privileged information, I am authorizing the following information also be disclosed. Check all that apply:

Mental Health RecordsHIV/STD RecordsSUD Records
Please provide detailed instructions on the ROI
I understand that I may revoke this authorization at any time with written notification, but that the revocation will not have any effect on the information released prior to notification of revocation. Please see your Notice of Privacy Practices for information on how to revoke this authorization. I also understand that this authorization will automatically expire one year from the date of my discharge from Anishinaabe Endaad unless I revoke it earlier. Anishinaabe Endaad will not refuse or revoke my treatment if I choose not to sign this authorization. A photocopy/fax of this authorization will be treated in the same manner as an original. You may, in the presence of Anishinaabe Endaad Staff, inspect or copy the information for use or disclosure with this Authorization for Disclosure.

I understand that substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164, and cannot be disclosed without written consent unless otherwise provided for by the regulations.

Further, I realize that Anishinaabe Endaad cannot prevent the redisclosure of records released as a result of this request and that the records may not be subject to privacy rule protections; therefore Anishinaabe Endaad is released from any and all liability resulting from redisclosure.
Authorization Signature*

Clear
Authorization Signature
Should be Empty:

Patient Authorization for Disclosure of Protected Health Information (Release of Information- ROI)*

Patient Information

Program Information

Anishinaabe Endaad

Agency or Person To Share Information With