Healthcare Release of Information (Roi) Form

HEALTHCARE RELEASE OF INFORMATION (ROI) FORM

Patient Name: Laura Smith

Patient DOB: Mar 18, 1987

Patient SSN or MRN: 100-00-8326

I authorize the release of information:

[X}FROM:

Family Clinic

NAME OF PROVIDER, PERSON, HEALTH CARE SYSTEM

2015 NW PCC Hospitals and Clinics Rd.

ADDRESS LINE 1

ADDRESS LINE 2

Portland, OR 97229

CITY/STATE/ZIP

[X} TO:

J.M. McDonald, Attorney at Law, M and M Law Firm

NAME OF PROVIDER, PERSON, HEALTH CARE SYSTEM

1616 Frontage Road

ADDRESS LINE 1

ADDRESS LINE 2

Portland, Oregon 23456CITY/STATE/ZIP

**************************************************************

INFORMATION TO BE RELEASED (also see specific authorization for release of

sensitive information below):

[ ] Any and all types of records you have for this patient

[ ] Doctor visit notes

[ ] Doctors orders

[ ] Emergency Room notes

[ ] Nurses notes

[ ] Urgent care notes

[ ] Discharge Summary

[ ] History and Physical

[ ] Lab reports

[ ] Hospital Progress Notes

[ ] Radiology Reports

[ ] Operation or procedure notes

[ ] Consultations

[ ] Clinic notes

[ ] Pathology reports

[ ] Other

[X} Only during a specific time period, from Jun 19,2011 to Jun 19,2011.

RELEASE OF INFORMATION

The following information will not be released unless you specifically

authorize it by marking the relevant box(es) below:

[ } YES [X] NO

I specifically authorize the release of my STD results, HIV/AIDS testing,

whether negative or positive, to the provider/person(s) listed above.

I understand that the person(s) listed above will be notified that I must

give specific written permission before disclosure of these test results

to anyone.

[ } YES [X] NO

I specifically authorize the release of any records regarding drug, alcohol,

or behavioral/mental health treatment to the provider/person(s) listed above.

[ } YES [X] NO

I specifically authorize the release of genetic testing information to the...