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Resolve ROI Authorization for the Release of Medical Record

Where are the records being release Form ?
Tell Us About the patient
Where are we sending the records?
What Would you like Released ? check all that apply

if you do not want certain portions of medical records released, please check the categories listed below you would like excluded

Purpose of Disclosure: Why are we sending records ?
Delivery Method: How would you like the records send ?
Patient's Signature

I here by authorize Resolve ROI and its affiliates to release or disclose to the person(s) 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.