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