ROI - Medical Record Request

Medical Record Request

Release of information (ROI)
I am
I am requesting

Please select the option that best describes your request:

- Parent/guardian/legal representative/authorized 3rd party/other Details
- Enter your name/entity
- Entity Tel #
- Email
- Which best describes their relationship to the patient
  
  Other
- Please upload documentation of your legal authority for this request and relationship with the patient. Please note, requests submitted without appropriate documentation will be closed
  
  Cancelof

- Patient Details
- Patient Name
- Birth Date
  
  MonthDayYear
  Date
- Phone Number
  Format: (000) 000-0000.
- Email
  example@example.com
- Email

Request records to
Name of Person/Entity
The party to whom records will be requested:
Person/Entity Tel#:
Please enter a valid phone number.Format: (000) 000-0000.
Person/Entity Fax#
(all medical records will be faxed to this number)Format: (000) 000-0000.

Genetic Test Request

Please fill out the form allowing us to share your information with Gene Sight. In the name section, please put " GenoMind- www.genomind.com, phone number: 877-895-8658." You can then checkmark what we are allowed to share with the company.
Name of Person/Entity LunaJoy is releasing/requesting information to:
Person/Entity Tel#:
Please enter a valid phone number.Format: (000) 000-0000.

Release To:
- Name of Person/Entity LunaJoy is releasing/requesting information:
- The party to whom records will be released/shared is:
- Person/Entity Tel#:
  Please enter a valid phone number.Format: (000) 000-0000.
- Person/Entity Fax#
  (all medical records will be faxed to this number)Format: (000) 000-0000.

- I understand that all record requests will be sent via Fax to the phone number above
- I understand that records and information may include information about Substance Abuse and/or Alcohol Abuse, HIV/AIDS, or STDs, and Mental Health Records.
- I understand there may be a fee for this release. I understand that all fees will be in compliance with applicable law. I agree to pay this fee. Medical records cannot be released until fees have been settled.
- I understand that all medical, surgical, psychiatric, and psychological information is confidential and that patient records are the property of LunaJoy Health Inc. and its related corporate entities. I will not hold LunaJoy, its employees, staff, or representatives responsible for any damage, mental or physical, which may be caused by the release of patient records and the information contained therein.
- I understand that my authorization for release may be revoked at any time by written request to LunaJoy at (care@hellolunajoy.com), but may not be revoked to include the release allowed by this document. Also, if this authorization is permission for LunaJoy to disclose information to an insurance company, in order for me to obtain insurance coverage, the insurance company may still have the legal right to use the information to contest my coverage.
- I understand that the person or organization that receives the information because of this authorization may disclose this information to other people or organizations without my knowledge or consent. Therefore, I hereby release LunaJoy, its employees, staff, and representatives from all liability relating to or arising out of this release of information contained in LunaJoy patient records.
- I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign and will not base my treatment or payment whether or not I provide authorization for the requested use or disclosure. I understand that I may inspect or copy the information to be disclosed as provided in CFR164.524 (with reasonable charge).
- This authorization shall expire when the client is discharged from the current episode of care (treatment has been completed, the client rejects/declines/drops out of treatment, is referred elsewhere, moves, or in the case of the client's death.) This agreement is subject to revocation in writing at any time.

If you are NOT the patient but are signing on behalf of the patient, please attach proof of your authority to act on behalf of the patient. If proof of authority is not attached, the request will be terminated.
File Upload

Cancelof
Print your name
Which best describes your relationship to the patient

Other
Signature
Date

MonthDayYear
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
- Should be Empty:

Medical Record Request

Parent/guardian/legal representative/authorized 3rd party/other Details

Patient Details

Request records to

Genetic Test Request

Release To:

Medical Records Request

Forms or Document Completion Request