APA AUTHORIZATION FOR RELEASE OF INFORMATION (ROI)

Release of Information Form

Patient Consent Form
Patient's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
RECIPIENT INFORMATION
Name of the Recipient

First NameLast Name
Address of Recipient

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Recipient

Area CodePhone Number
Fax Number of Recipient

Area CodePhone Number
Email of Recipient
example@example.com
The information to be released are as follows (check all that apply):

Other
Purpose of Disclosure (check one):

Other
AUTHORIZATION TERMS
I understand that this authorization for the release of my health information will remain effective for (check one):

Other
This authorization will expire on: ___ blank
If no date is specified, this authorization will expire one year from the date of signature.
I understand that:
- My health information is protected under the Health Insurance Portability and Accountability Act (HIPAA).
- The recipient of this information is required to comply with applicable federal and state laws governing confidentiality.
- This is a standing authorization, and only the information specified above will be released.
- I may revoke this authorization at any time in writing, except to the extent that action has already been taken based on this authorization.
- Refusal to sign this authorization will not affect my right to receive treatment.
Date of Signing

MonthDayYear
Date
Signature
Person Completing this form (If not the patient)

First NameLast Name
Relationship to Recipient
Phone Number

Area CodePhone Number
Should be Empty:

Release of Information Form

RECIPIENT INFORMATION

AUTHORIZATION TERMS