Please fill out the form below. If you would like to print a physical form, it can be found here.
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: The specific information that should be disclosed is (please give dates of service if possible):*
Disclose information about alcohol/substance abuse, HIV/AIDS, or mental health?*
3: 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.
4: 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.
5: My purpose/use of the information is for:*
6: This authorization expires on:*
OR upon occurence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me:
Signature:* (Use your mouse to draw in the box below)
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Please fill out all required fields.