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ResolveROI Patient Authorization for the Release of Medical Records

What Facility Are Records Being Released From?
Patient Information
Dates of Service Requested

Where Are We Sending The Records?
What PHI (Personal Health Information) Would You Like Released?

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 sent ?
Patient's Signature

I hereby authorize ResolveROI 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 Psychological or Psychiatric Impairments, Drug Abuse, Alcoholism, Sickle Cell Anemia or HIV/AIDS 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 writer notification and it will not affect any information released prior to notification of 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 federal regulation. I understand I can refuse to sign this authorization and my healthcare provider may not condition treatment on my signing this authorization.


(click the pen and paper icon to sign)