ROI Form

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Authorization to Release Confidential Records and Information

 A previous Release of Information (ROI) dated / / is revoked by this ROI. The recipient identified in
the previous ROI may be informed that that ROI has been revoked.

A. Identifying information about me/the patient


Name: Kaden Mays Date of birth: 07 / 27 / 03
Other name(s) used/AKA:
Current address: , 48 Brighton Ave, Allston, MA 02134
Address at time of treatment: 48 Brighton Ave, Allston, MA 02134
Current phone(s): (479) 657-5519 Medical record #:
Name of parent/guardian (if applicable): Phone #:
Address of parent/guardian:

B. Because I believe it is in my/our best interest, I hereby authorize the release of information described below:

FROM: SOURCE TO: RECIPIENT


Person or organization: Person or organization:
Dr. Heidi Thermenos Jenny P. Melguizo
Address: 1101 Beacon St, Brookline, MA, 02446 Psychiatric Mental Health Nurse Practitioner
Mob : (617)819-4511
Phone: (781) 606-1962 Fax number: Fax : (617)934-2683
E-mail : [email protected]
Secure email: [email protected] 399 Boylston Street, Suite 900A
Attention of: Boston, MA 02116

C. The records to be disclosed are marked by an × in the boxes below. The items not to be released have a line
drawn through them. All episodes of care are to be included unless page numbers and/or dates are indicated.
 Inpatient or outpatient treatment records for physical/medical and/or psychological, psychiatric, or emotional
illness
 Date(s) of inpatient admission: / / to / /
 Date(s) of outpatient treatment: / / to / /
 Other identifying information about the service(s) rendered:

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 Psychological evaluation(s) or testing records, and  Psychiatric evaluations, reports, or treatment notes
behavioral observations or checklists completed by and summaries
any staff member or by the patient
 Admission and discharge summaries

 Treatment plans, recovery plans, aftercare plans  Information about how the patient’s condition affects
or has affected his or her ability to complete tasks,
 Social, family, developmental histories activities of daily living, or ability to work
 Assessments with diagnoses, prognoses, and  Billing records
recommendations, and all similar documents
 A letter containing dates of treatment(s) and a
 Workshop reports and other vocational evaluations summary of progress
and reports
 Academic or educational records

 Other records:

HIV-related information and drug and alcohol information contained in these records will be released under this
consent unless indicated here: Do not release HIV-related information. Do not release drug and alcohol
information.

 I authorize the re-release of any information obtained from other sources presently in the records of the person or
facility indicated in section B.

D. I authorize the transfer of these records for the following purpose(s) or uses:
 Further mental health evaluation, treatment, or care  Rehabilitation program development or services
 Treatment planning  Research  Qualification for services or benefits
 Other:

E. I authorize the Source named in section B above to speak by telephone and/or face to face with the Recipient in
section B about the reasons for my/the patient’s referral, any relevant history or diagnoses, and other similar
information that can assist with my/the patient’s receiving treatment or being evaluated or referred elsewhere.

F. I understand the consequences if I refuse to allow this release. I may not receive services by the recipient or at the
recipient organization. The cost of services I may receive may not be reimbursed to any degree and so will be entirely
my responsibility. I may not be eligible for programs or services that could be beneficial to me. Other
consequences have been explained to me. My consent is fully voluntary.

G. This request/authorization to release confidential information is being made in compliance with the terms of the
Privacy Act of 1974 (Public Law 93-579) and the Freedom of Information Act of 1974 (Public Law 93-502), and
pursuant to Federal Rule of Evidence 1158 (Inspection and Copying of Records upon Patient’s Written Authorization).
This form is to serve as both a general authorization, and a special authorization to release information under the
Drug Abuse Office and Treatment Act of 1972 (Public Law 92-255), the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation Act Amendments of 1974 (Public Law 93-282), the Veterans
Omnibus Health Care Act of 1976 (Public Law 94-581), and the Veterans Benefit and Services Act of 1988 (Public
Law 100-322). It is also in compliance with 42 C.F.R. Part 2 (Public Law 93-282), which prohibits further disclosure
without the express written consent of the person to whom it pertains, or as otherwise permitted by such regulations.
It is in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191,
and with the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, Public Law 111-
5.

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H. I understand that if the person or organization that receives this information is not a health care provider or health
care insurer (or other covered entity under HIPAA), the information may no longer be protected by federal privacy
regulations. It may, however, be protected under other laws and regulations. I understand that the Source of the
information has no control of it after it has left the Source’s premises.

I. In consideration of this consent, I hereby release the Source of the records from any and all liability arising from the
release of these records.

J. I understand that I may cancel and revoke this ROI authorization, but that doing this will not bring back the
information that was released before the ROI was revoked. I can do this at any time by writing to the person or
organization named in paragraph B as the Source telling them that I want the ROI revoked.
If I do not revoke this ROI authorization, it will automatically expire 90 days from the date I signed it OR
on this date: / / OR when this event about me occurs: OR
when the use or purpose of this information about me is completed.

K. I agree that a photocopy of this form is acceptable, but it must be individually signed by me, the releaser, and a
witness if necessary.

L. I have been informed of the risks to privacy and limitations on confidentiality of the use of facsimile machines and
electronic means of information transfer, and I accept these.

M. I understand that I have the right to inspect and receive copies of the information to be released.
 I have OR I have not reviewed the records to be released.

N. I understand that the Source will not receive compensation for the disclosure of this information.

O. I will pay a reasonable fee for the copying/printing and postage or other delivery costs (if I choose these records to
be sent) but will not have to pay for the retrieval of these records.

P. I have had the provisions of this form explained to me and believe that I fully understand this ROI, including the
nature of the records, their contents, and the likely consequences and implications of their release or of my refusal to
release them. I also understand that I have the right to receive a copy of this form upon my request.

Q. Signatures:

Kaden Mays 11 / 22 / 22
Signature of patient Printed name Date

Signature of parent/guardian/representative if needed Printed name

/ /
Relationship Date

I witnessed that the person understood the nature of this ROI and freely gave his or her consent, but was physically
unable to provide a signature.

/ /
Signature of witness Printed name Date

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