if you do not want certain portions of medical records released, please check the categories
listed below you would like excluded
I here by authorize Resolve ROI and its affiliates to release or disclose to the
or organization listed above, all medical records requested, including any specially
protected records such as those relating to Pyschological or psychiatric
impairments, durg abuse ,alcoholism,sickle cell anemia or HIV infection ,unless otherwise
noted. The authorization is valid for 12 months from the date of signature.
I understand that I may cancel this request with writter notification that it will not
affect any information
released piror to notification cancellation. I understand that the information used or
disclosed may be subject to re-disclosure by the recipient listed above and will no longer
be protected by fedral regulation. I understand
I can refuse to sign this authorization and my healthcare provider may not Condition
treatment on my signing this authorization.