Release of Information Form

Authorization for Release of Medical Record Information
Patient Information
Patient Name

First Name Last Name
Patient Birth Date

Month Day Year
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 Name Last Name
Outside Provider Practice or Organization Name
Outside Provider/Individual Phone Number

Area Code Phone Number
Outside Provider/Individual Fax Number

Area Code Fax Number
Outside Provider/Indiviudal Email Address
Outside Provider/Individual Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Details of Release of Information
Please indicate release to/from West Cary Psychiatry or both:

To release information to another party: I authorize release of information/records listed below from West Cary Psychiatry to the person/organization listed above. This is being requested for the purpose of ongoing treatment.To release information to West Cary Psychiatry: I authorize release of information/records listed below to West Cary Psychiatry from the person/organization listed above. This is being requested for the purpose of ongoing treatment
Section 2: The specific protected health information that I request to be disclosed is (choose all that apply):

Progress/Treatment NotesRecords related to Substance AbuseAdmission History and PhysicalDischarge SummaryPsychological Testing/Neurocognitive TestingLaboratory ResultsDiagnostic Imaging ResultsContinuity of Care/Coordination of Care communication between providers
Other Protected Health Information to be released (if not listed above)
Dates of Treatment covered by this ROI (if known):
Dates of Treatment: Beginning

MonthDay Year
Date
Dates of Treatment: End

MonthDay Year
Date
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.

MonthDay Year
Date
Signature of Patient or Representative

Clear
Date of Signature

MonthDay Year
Date
Name and relationship of Representative (if not patient)
Should be Empty:

Authorization for Release of Medical Record Information

Patient Information

Outside Provider or Individual Information

Details of Release of Information