UofL Health Release of Information (ROI) Form

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION / ACCESS TO PROTECTED HEALTH INFORMATION FORM

Instructions for Completing Authorization for Release of Information Form

Complete All Questions
Section l: enter your name and date of birth or the name and date of birth of the patient whose health information is to be released and select the facility records are needed.
Section Il: enter the name and full address of the facility/individual to receive the health information being released.
Section Ill: check the appropriate box as applicable to select the type of medical records you want released.
1. All Records -- complete record including, if authorized, the sensitive information such as alcohol and drug abuse treatment/referral, sexually transmitted diseases, HIV/AIDS-related treatment, and mental health other than psychotherapy notes.
Section IV: enter the date range of medical records to be released. Specify date range, e.g., Jan. 1 , 2002, to Feb. 1, 2002.
Section V: state the reason why the information is needed, e.g., court, continued medical care, etc.
Section VI: check the appropriate box to indicate the format in which to release the health records.

IN ORDER TO RELEASE SENSITIVE INFORMATION REGARDING ALCOHOL/DRUG ABUSE
TREATMENT, HIV/AIDS-RELATED TREATMENT, SEXUALLY TRANSMITTED DISEASES AND/OR MENTAL HEALTH RECORDS (OTHER THAN PSYCHOTHERAPY NOTES), THE APPROPRIATE BOX OR BOXES MUST BE CHECKED BY THE PATIENT.

8. A copy of the completed Authorization for Release of Information Form (UL840020) will be given to you with your medical record when released.

Section I:

Patient Demographics

Patient First Name *

Patient Middle Name

Patient Last Name *

Date of Birth *

Month / Day / Year

Physician Name

Section II:

Who Will Receive My Protected Health Information (PHI)?

Facility or individual to receive my PHI *

Facility Contact

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Phone Number *

Fax Number

Section IV:

Date(s) of Treatment to be Disclosed

From Date *

Please Input Date MM / DD / YYYY

To Date *

Please Input Date MM / DD / YYYY

Expiration Date / Event

Section V:

Section VI:

Medical Record Format

If Requesting PHI be Faxed, Enter Fax Number Here

If Requesting PHI be Emailed, Enter Email Address Here

Legal Terms and Conditions *

EXPIRATION OF AUTHORIZATION TO DISCLOSE PHI If this authorization has not been revoked, it will expire ninety (90) days from the date of submission unless a different expiration date or expiration event is provided above. REVOCATION, CONDITIONS AND RE-DISCLOSURE REQUIREMENTS 1) I understand that I may revoke this authorization in writing submitted at any time to the Health Information Management Department, except to the extent that action has been taken in reliance on this authorization. UofL Health, Attn: Release of Information 225 Abraham Flexner Way, Suite 650, Louisville, KY 40202 Email: ULHHlMROl@uoflhealth.orq Fax: 502-627-1806 2) I understand that the Hospital will not condition treatment on me signing this authorization, unless (a) I am receiving research-related treatment or (b) the only reason the health care is provided is to make a report to a 3rd-party, such as my employer (e.g. fitness to return to work) or school (e.g. P.E. physical). 3) I understand that the information used and/or disclosed according to this authorization may no longer be protected by federal privacy law (also known as HIPAA) and that the recipient of my health information may potentially redisclose it; except for substance abuse information that may be prohibited by law (42 CFR Part 2).

Consent *

I understand that the medical record released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above. If UofL Health is asking to use/disclose my information, I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, enrollment in any health plan, or payment/benefit eligibility. I may inspect or copy any information used/disclosed under this authorization.

Signature

Signature Date

Please input date (MM/DD/YYYY)

What is your relationship to the patient? *

I am the patient
Power of Attorney (POA)
Executor or Administrator of deceased patient's estate
Legal Guardian
Personal Representative
Parent or legal Guardian for the child to which I am requesting records

Please upload Drivers License