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 in one year, unless otherwise stated here:
(Please note: if current date used this authorization will only be valid for one day.)
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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