Authorization of Disclosure
of Medical Records

Please fill out the form below. If you would like to print a physical form, it can be found here.

Patient's Full Name(Required)
MM slash DD slash YYYY
I hereby authorize Ortho RI to disclose protected health information about me as described below:
1: The following person (or class of persons) may receive disclosure of protected health information about me:
2: Please indicate how you would like your records sent(Required)
3: The specific information that should be disclosed is (please give dates of service if possible):(Required)

Disclose information about alcohol/substance abuse, HIV/AIDS, or mental health?(Required)

4: I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
5: I may revoke this authorization by notifying Ortho RI in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reserved, and my revocation will not affect those actions.
6: My purpose/use of the information is for:(Required)
7: This authorization expires in one year, unless otherwise stated here:
MM slash DD slash YYYY
(Please note: if current date used this authorization will only be valid for one day.)
8: Date of request(Required)
MM slash DD slash YYYY

    NOTICE: MRI imaging at our Providence office is currently unavailable due to construction. We appreciate your patience as we work to improve your experience!