FAMILY TREE CLINIC ROI (RELEASE OF INFORMATION)

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Date of Birth:* This field is required.
Date
Month
Day
Year
2
Legal Name* This field is required.
Legal Last Name
First Name
3
Preferred Name:
4
Social Security #
5
Address:
6
City:
7
State:
8
Zip:
9
Provider Name:* This field is required.
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Name of Clinic or Hospital (Who has the information you want released? Please list the specific clinic or provider.)* This field is required.
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Address:
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City:
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State:
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Zip:
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Phone:* This field is required.
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Fax:
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Name:* This field is required.
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Address
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City:
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State:
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Zip:
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Phone:
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Fax:
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Please indicate date(s) of service:
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Visit notes
Hormone related care
Hospital
STI results
Pap smear / colposcopy / pathology
26
Initial to include HIV results in STI results
Clear
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Any and all records
Any and all records
28
Initial to include HIV results with "Any and all records"
Clear
29
Only records types checked below:
Laboratory reports
Emergency records
Medication records
Immunization records
Ok to discuss protected health information (no records needed unless indicated above)
Imaging reports
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Chemical dependency results
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Initial for chemical dependency results
Clear
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Mental health results
33
Initial for mental health results
Clear
34
HIV test results
35
Initial for HIV results
Clear
36
Release Instructions
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Date information is needed:* This field is required.
Date
Month
Day
Year
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Purpose of Release* This field is required.
Continuing care
Personal use or review
Insurance payment/claim
Transfer of care
Legal
Other
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Receive records by:* This field is required.
Mail
Pick up
Fax
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This authorization lasts for one year unless otherwise requested. I would like my authorization to expire 14 days after the following date:
Date
Month
Day
Year
41
You may cancel this authorization at any time by writing to Family Tree Clinic. A cancellation will not change releases that happen before the cancellation

A photocopy/fax of this authorization will be treated in the same way as an original.

Family Tree Clinic may include records that it received from other organizations. If these records have been used by Family Tree Clinic and filed in the record Family Tree Clinic maintains about you, these records may be released with your Family Tree Clinic records.

Family Tree Clinic cannot prevent redisclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release Family Tree Clinic from any and all liability resulting from a redisclosure by the recipient.

Family Tree Clinic will not condition treatment, payment, enrollment or eligibility for benefits on whether or not you sign this form.

Your signature indicates that you have read and understand this form, and authorize release of your information as described above
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Patient/Legal Guardian Signature* This field is required.
Clear
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Today's date* This field is required.
Date
Month
Day
Year
Should be Empty: