Medical Record Release Form (ROI FORM)
Patient Information
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to Release Information
HealthCare Provider/Physician/Medicare Contractor Name
Title
First Name
Last Name
Organization Name
Phone Number
Fax Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to Receive Information
Name
First Name
Last Name
Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Fax
Release Details
I, the patient, authorize and request the disclosure of all protected information I select below full and complete.
All medical records
All physical, consults, office and telemedicine notes.
All laboratory, histology, cytology, pathology, immunohistochemistry record and specimens; radiology records and films( this includes, FIT, Cologuard, mammograms and pap-smears)
All pharmacy/prescription records
immunization records
Other
Disclosed Purpose(s) of Protected Health Information
I, the patient, agree with the following statements:
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I am giving my consent to release or disclosure this type of information.
I understand this authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.
I understand I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
I understand my treatment or payment for my treatment cannot be conditioned on the signing of this authorization.
I understand this authorization shall be effective for two years from date of execution at which time this authorization expires.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: