ROI-RECEIVING

AUTHORIZATION FOR USE OF PROTECTED HEALTH INFORMATION

COMPLETE ALL SECTIONS, DATE AND SIGN
Patient Information
Patient Name*
Last, First, MI
Patient Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, Name of Patient*, hereby voluntarily authorize the disclosure of information from my health record.
Name of Facility.
Address of Facility.
City/State of Facility.
Name of facility information is to be disclosed by:*
Address of facility information is to be disclosed by:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The purpose or need for this disclosure is:*

Further Medical CarePersonal UseAttorneyInsuranceSchoolDisabilityResearchHealth Information ExchangeOther
Please specify the Health Information Exchange (IHS or Other).
The information to be disclosed from the patient's health record (check all appropriate boxes, AT LEAST ONE OF THE FOLLOWING MUST BE SELECTED):
Only information related to:Specify Here
Only the period of events from:Date   to:   Date
Other:   (CHS, Billing, Etc.)
Entire Record
If you would like any of the following sensitive information disclosed, check the applicable boxes below:

Alcohol/Drug Abuse Treatment/ReferralSexually Transmitted DiseasesHIV/AIDS Related TreatmentMental Health (Other than Psychotherapy Notes)Psychotherapy Notes ONLY (by checking this box I a waiving any psychotherapist-patient privilege)
Signature of patient or personal representative:*

Clear
Date:*

MonthDayYear
Date
Relationship to patient (if personal representative):
Should be Empty:

AUTHORIZATION FOR USE OF PROTECTED HEALTH INFORMATION

Patient Information