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AUTHORIZATION TO
RELEASE OF INFORMATION
PATIENT IDENTIFICATION LABEL
AUTHORIZATION TO
RELEASE OF INFORMATION
*ROI*
1. PATIENT INFORMATION
MRN (OFFICE USE ONLY):
Last Name First middLe maideN
address City state Zip
DOB SSN
(LAST 4 DIGITS)
preFerred phoNe
LEAVE MESSAGE
(CHECK TO LEAVE MESSAGE)
2. REASON FOR REQUEST
CONTINUITY OF CARE - MEDICAL TREATMENT INSURANCE LEGAL REASONS DISABILITY
RESEARCH ADOPTION EMPLOYMENT RELATED
Other (Describe)
3. INFORMATION TO BE DISCLOSED BY (please specify location in space provided):
HOSPITAL
FREESTANDING ED
URGENT CARE
ALL OHIOHEALTH LOCATIONS
HEALTH CENTER
PHYSICIAN OFFICE
OTHER:
4. DATES OF SERVICE TO BE RELEASED:
DATE/YEAR OF SERVICE(S): FROM TO
5. RECORDS TO BE RELEASED (CHECK ALL THAT APPLY):
AFTER VISIT SUMMARY OPERATIVE REPORT(S) PLEASE SPECIFY:
DISCHARGE SUMMARY EMERGENCY DEPT. REPORT(S) RESULTS:
HISTORY AND PHYSICAL PATHOLOGY OTHER:
CONSULTS RADIOLOGY/IMAGES PHYSICIAN OFFICE NOTES:
LABS RECORD SUMMARY (INCLUDES, BUT
NOT LIMITED TO, ITEMS ABOVE)
6. DELIVERY METHOD:
US MAIL PICK-UP CD
EMAIL MYCHART CIOX E-PORTAL
(limited per le size)
Email Address
The CD/email you have requested is encrypted. If you agree to have the
encryption removed by OhioHealth, please initial below. By removing the
encryption, your personal health information will no longer be secured.
INITIALS:
7. RELEASE TO:
NAME OF PERSON/ORGANIZATION/CLINIC: Self
ADDRESS: CITY: STATE: ZIP:
PHONE: FAX:
8. PROHIBITION ON REDISCLOSURE:
I understand this information has been disclosed from records whose condentiality is protected by Federal law. Federal regulations (42 CFR part 2) may prohibit
you from making any further disclosure of this information except with the specic written consent of the person to whom it pertains. A general authorization for
the release of medical or other information, if held by another party, is not sufcient for this purpose. Federal Regulations state that any person who violates any
provision of this law shall be subject to prosecution under Federal law.
9. FEES: Per Ohio Revised Codes and HIPAA, there may be a charge for copying medical records
10. AUTHORIZATION AND EXPIRATION:
+ I understand that if the person or entity that receives the above information is not a health care provider or health plan covered by federal privacy regulations, the
information described above may be redisclosed by such person or entity and will likely no longer be protected by the privacy regulations.
+ OhioHealth will not condition treatment, payment, enrollment or eligibility for benets on whether you sign the authorization when the prohibition on condition
of authorizations applies.
+ I understand by signing this authorization it gives the researcher(s) the permission to use or disclose my personal health information for such research.
+ I understand that my records/protected health information cannot be released unless I sign this form.
+ I understand that this authorization may include information concerning testing, diagnosis or treatment of HIV (Human Immunodeciency Virus), AIDS
(Acquired Immunodeciency Syndrome), PSYCHIATRIC and/or DRUG/ALCOHOL TREATMENT and/or ASSAULT RECORDS that may be in my medical record.
+ As described in the Notice of Privacy Practices of OhioHealth, I understand that I may revoke this authorization in writing at any time, except to the extent
that action has been taken by OhioHealth in reliance on this authorization, by sending a written revocation to the entity’s Health Information Management
Medical Records Department. If this authorization has not been revoked, it will expire on the date or event stated below. If no date is specied below, the
authorization will remain in effect for a maximum of one year.
Expiration Date or Event:
X Signature of Patient Date Time
Signature of Individual Authorized by Patient Date Time
