ROI
Authorization to Use or Disclose Health Information
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Clinic
*
is authorized to release patient health information as follows:
Information to be used or disclosed:
*
Entire record including, without limitation, personal health information and other records pertaining to treatment, payment or services sought or received, including non-medical services and the records listed below(if this box is checked, all boxes below are presumed to be checked)
Admission/Intake Summary
Psychosocial History
Treatment Plan
Discharge Summary
Psychological Evaluation
Psychiatric Evaluation
Educational Assesments
Health History/Physical Records
Lab Reports
Medication Records
HIV Status
Immunization Records
Substance Abuse Treatment
Progress Notes
Psychotherapy Notes CAN NOT be released with this Authorization – provide a separate Psychotherapy Authorization to obtain those records
Name of Organization(s), person(s), or class of persons authorized to receive health information:
*
Purpose(s) for which health information may be used/disclosed
At the request of the individual’s personal representative
Other (specify)
Authorization Expires On:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
If this section is not completed, authorization expires one year from date of signature.
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
I agree to the HIPAA Privacy Statement
Please verify that you are human
*
Submit
Should be Empty: