ROI (Release of Information)

Name *

First

Middle

Last

Date of Birth *

SSN *

Person / Place Releasing Information *

Name of the Person / Location / or Establishment for records Ex: Spouse-Firstname/Lastname | Mercy Medical Center | University of Iowa

Address *

Phone Number *

Fax Number *

Where Information Should Be Sent *

Name of the Person / Location / or Establishment for records Ex: Spouse-Firstname/Lastname | Mercy Medical Center | University of Iowa

Send to Address *

Send to Phone Number *

Send to Fax Number *

Check here if both parties will be receiving and releasing information

Information Requested *

Complete Records
Demographics
Notes
Other

If Other

Purpose of Release *

Continuity of Care
Transfer of Care
Other

If Other

Desired Release Expiration Date *

I understand that this will include information relating too (all must be checked) *

Substance Abuse (Alcohol/Drug)
Mental Health (Includes Psychological Testing)
HIV - Related Information (AIDS-Related Testing)
I give my consent to fax and/or mail my records
I understand that Meadowlark Psychiatric Services may receive compensation for the disclosure of information released pursuant of this authorization

Release Agreement *

I Agree

I give Meadowlark Psychiatric Services or the named agency my permission to release only the information I have selected on this form to the individual(s) or agency(ies) I have named and only for the purpose I have checked. I Understand that this release is valid up to the experation date stated below, and I may refuse to sign this authorization at anytime. Any revocation or refusal to sign this authorization will not effect my ability to obtain treatment, payment or my eligibility for benefits. The revocation will take effect on the day it is received in writing. As a patient, I have the right to access my treatment records. Copies of the records may be obtained with reasonable notice and payment for the copying cost. I further understand that the person or entity that receives the above specified information is not a health provider, health plan, or health care clearinghouse covered by the federal privacy regulations or a business associate of these entities, the information described above may be redisclosed and no longer protected by the regulations.

Electronic Signature Disclosure *

I Accept

By selecting the "I Accept" button, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Meadowlark or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and GYV Inc. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement.