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)

Street Address(Required)

City,State,Zip(Required)

Phone Number(Required)

Email(Required)

Date of Birth(Required)

ORI Physician Name(s)(Required)

Select Office Location

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:

Full Name(Required)

Street Address(Required)

City,State,Zip(Required)

Phone Number(Required)

Fax Number

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)

yes

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:

Date

(Please note: if current date used this authorization will only be valid for one day.)

8: Date of request(Required)

Date of request(Required)

Specialities

Services

Authorization of Disclosure
of Medical Records

Specialities

Services

Authorization of Disclosure of Medical Records

Authorization of Disclosure
of Medical Records