FTC ROI (RELEASE OF INFORMATION)

1
Legal Name* This field is required.
Legal Last Name
First Name
2
Date of Birth:* This field is required.
Date
Month
Day
Year
3
Phone Number
Please enter a valid phone number.
4
Preferred Name/Pronouns:
5
I authorize Family Tree Clinic (1919 Nicollet Ave S, Minneapolis MN 55403, Phone: 612-473-0800, Fax: 612-236-4745)
Send records to
receive records from
Share Protected Health Information with
6
Provider/Clinic/Hospital Name:* This field is required.
7
Street Address:
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City:* This field is required.
9
State:* This field is required.
10
Zip:
11
Phone:
12
Fax:
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RECORDS TO BE EXCHANGED
visit notes
medication records
STI results
immunization records
laboratory reports
imaging reports
pap smear/colposcopy (request >1 year below)
hospital/emergency reports
Other
14
Initial for HIV results
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15
Include chemical dependency records
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16
Include mental health records
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Purpose of Release* This field is required.
Continuing / Transferring Care
Legal
Personal review
Insurance payment/claim
Other
18
Send records via* This field is required.If fax is not available, also okay to send mail or pick up (at Family Tree Clinic)
Fax (preferred)
Mail (if fax is not possible)
Pick up (if fax is not possible)
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Date range of services for records
One year prior to signature
Other
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Additional Information Regarding Request:
Huge
Large
Normal
Small
Ok
Ok
21
Authorization lasts for one year unless otherwise requested. I would like my authorization to expire 14 days after the following date.
Date
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.
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23
Today's date* This field is required.
Date
Month
Day
Year
Should be Empty: