Release of Information (ROI) Form
Use this secure form to authorize Hope and Healing Clinic to exchange health information with another provider or organization to support your care, treatment coordination, or transfer of services.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address (optional)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorization to Exchange Health Information
Please provide the information for the provider or facility that holds the records you authorize to be shared with Hope and Healing Clinic
Referral Agency / Organization Name
*
Facility Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Facility Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Purpose of Disclosure
Purpose of Disclosure
Continuity of Care
Transfer
Communication with Care Team
Billing
Other
Information Requested / Authorized to Exchange
We request that the following records be sent to Hope and Healing Clinic:
OUD Treatment Summary (including authorizations below)
Hospital H&P and Discharge Summary
Medication List
Immunization History
Problem List
Last Three Progress Notes
Test Results
None; establishing two-way release of information
Ongoing Authorized Information Exchange
Specify the health information you authorize to be exchanged today and in the future until expiration date below:
Initial Screening
Diagnoses and Problem List
Biopsychosocial Assessment
Treatment Recommendations
Medical Records
Test Results
Recovery Plan and Progress
Treatment Recommendations and Referrals
Dosing History
Face Sheet and Copy of ID
Other
Sensitive Information
The following information will not be released unless specifically authorized below. By checking the box, I authorize release of that information:
Drug and alcohol abuse, diagnosis, or treatment (42 C.F.R. §§ 2.34–2.35)
Mental health diagnosis or treatment (Welfare & Institutions Code §§ 5328 et seq.)
HIV/AIDS test results (Health & Safety Code § 120980(g))
Genetic testing information (Health & Safety Code § 124980(j))
Expiration & Revocation
Unless otherwise revoked, this Authorization expires 12 months after the date of signing. I understand that I may revoke this authorization at any time by submitting a written request to Hope and Healing Clinic, except to the extent that action has already been taken in reliance on it. This authorization is voluntary. My treatment, payment, enrollment, or eligibility for benefits will not be affected if I do not sign this form. Once information is disclosed under this authorization, it may be subject to re-disclosure and may no longer be protected by federal privacy regulations (45 CFR Parts 160 & 164). Records released under this authorization are protected under HIPAA and 42 CFR Part 2, which prohibit further disclosure without my written consent.
Format & Method of Exchange
Records may be sent by secure fax, encrypted email, or uploaded via secure portal.
Requested Format:
Written
Verbal
Signature
Name
*
First Name
Last Name
Signature (Patient / Parent / Guardian):
*
Date
*
-
Month
-
Day
Year
Time
*
Hour Minutes
AM
PM
AM/PM Option
Relationship to Patient (Parent, Guardian, Conservator, Patient Representative)
*
NOTICE
Submit
Should be Empty: