TMS ROI Form

AUTHORIZATION TO RELEASE COPIES OF MEDICAL RECORD AND/OR FOR VERBAL COMMUNICATION FROM ANOTHER AGENCY
Patients Full Name:*
Date of Birth:*

MonthDayYear
* Is Authorized to release information to: Dr/Agency/Person*.
Regarding care in the following manner (check 1 or both):*

Verbal DiscussionSend Copy of Medical Records
Release information for the time period of:* to Type a label* OR Type a label* All episodes of treatment.
Information released is for the following purpose:*

Follow Up CarePersonal UseLegalSchoolDisabilityFamily InvolvementOther
I authorize the following portions of the above person's medical record be released to the above listed recipient:*

Admission History/Inital EvaluationPhysical Exam/Medical ConsultationsPhysician Prograss NotesFamily Therapy NotesDischarge SummaryDischarge Order FormLab ReportsPsychosocial EvaluationSubstance Abuse AssessGroup Therapy NotesNursing NotesPhysicians Orders
I understand these records include drug/alcohol/mental health/communicable disease-related information. I understand that information released could contain reference to results of HIV antibody testing. A photocopy of this authorization should be considered as valid as the original. This consent is subject to revocation by the undersigned at any time, except to the extent that action has been taken in reliance hereon and in any even shall expire within 90 (ninety) days from the date of signature. The information being authorized to release is being disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2 A general authorization for the release of medical or other information is not sufficient for theis purpose. The information to be released is PRIVILEGED and CONFIDENTIAL and is intended ONLY for the use of the recipient named above.
Signature of Patient or Legal Guardian:*

Clear
Relationship to Patient:*
Date:*

MonthDayYear
Should be Empty: