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Release of Information

(ROI) Form

Authorization to Release Information

I, voluntarily authorize Saban Community Clinic to disclose my health information also known as Medical Records from the patient named below and released to the named recipient or organization of my choosing.

Please complete all sections of the form and use your legal name and information specified on your official identification card or letter.

Patient Information

Please use legal name and information. This information needs to match your valid form of identification with photo.

Recipient Information

Please provide the full name of the recipient, personal representative or organization you want your records sent to. Type “Self” if the records are to go to you:

What is the purpose for requesting records? (select one)

Please choose what you want to release from your medical record:

How do you prefer to receive the records?

By signing this Authorization for Release of Information you agree to the following terms:

Health information released by this authorization (except for Alcohol and Drug Abuse) may be subject to release by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA), Privacy Rule and the Privacy Act of 1974.

Copies of medical records not picked-up within 30 business days of the date of this request date will be destroyed and a new Authorization to Request for Information may need to be submitted again.

I understand that I may revoke this authorization in writing by submitting the request at any time to Saban Community Clinic’s Medical Records Department, otherwise this authorization is valid for 1 full year from the date it was signed.

The release of authorization expires 1 full year from the date the authorization was signed, however you have the option to change the release authorization expiration date. Enter new expiration date here:

Please upload a valid form of identification with photo ID. E.g. Drivers License, State Issued ID, Military ID, etc. We accept the following image formats JPEG, JPG, PNG, GIF, and TIFF. Max file size is 4 Megabytes (MB).

Please use your mouse or touchpad to sign your name in the grey section below, then click “Submit Form” to submit your request.