Release of Information Form

Authorization for Release of Medical Record Information for Computerized Cognitive Testing
Patient Information
Patient Name

First NameLast Name
Patient Birth Date

MonthDayYear
Patient Email
example@example.com
Outside Provider or Individual Information

The organization or person that is to obtain/release records
Outside Provider/Individual Name

First NameLast Name
Outside Provider Practice or Organization Name
Outside Provider/Individual Phone Number

Area CodePhone Number
Outside Provider/Individual Fax Number

Area CodeFax Number
Outside Provider/Indiviudal Email Address
Outside Provider/Individual Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Details of Release of Information
Please indicate release to/from West Cary Psychiatry or both:
Section 2: The specific protected health information that I request to be disclosed is (choose all that apply):
Other Protected Health Information to be released (if not listed above)
Dates of Treatment covered by this ROI (if known):
Dates of Treatment: Beginning

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dates of Treatment: End

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Section 3: I understand that the information or records sent to West Cary Psychiatry may be incorporated into my medical record and will become part of my protected health information at West Cary Psychiatry. I understand that my treatment at West Cary Psychiatry will not be conditioned on whether or not I sign this authorization.
This authorization will expire either on the date listed below or in one year from the date of the signature below if no date is indicated, or sooner if I revoke this authorization in writing.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Patient or Representative
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name and relationship of Representative (if not patient)
Should be Empty:

Authorization for Release of Medical Record Information for Computerized Cognitive Testing

Patient Information

Outside Provider or Individual Information

Details of Release of Information