ROI
Richmond Heath Information Management Service Center (HSC) Release of Information
7300 Beaufont Springs Drive, Richmond, VA 23225
Phone: 877-302-7338 Fax: 855-330-4290 (Patient) 855-226-6070 (Physician)
Email for Patients Only: PARA.RICHHSCROIPatient@Parallon.com
Revised 1/2019
Section A: This section must be completed for all Authorizations
Patient Name: Date of Birth: Patient’s Phone: Last 4 digit SSN
(optional)
Hospital Name: Recipient’s Name:
Hospital Address:
Address 1:
Address 2: Recipient’s Phone:
City: State: Zip:
Request Delivery (If left blank, a paper copy will be provided): Paper Copy Electronic Media, if available (e.g., USB drive,
CD/DVD, eDelivery)
Encrypted Email Unencrypted Email
NOTE: In the event the facility is unable to accommodate an electronic delivery as requested, an alternative delivery method will be
provided (e.g., paper copy). There is some level of risk that a third party could see your PHI without your consent when receiving
unencrypted electronic media or email. We are not responsible for unauthorized access to the PHI contained in this format or any risks
(e.g., virus) potentially introduced to your computer/device when receiving PHI in electronic format or email.
Email Address (If email checked above. Please print legibly):
Purpose of disclosure:
Description of information to be used or disclosed
Is this request for psychotherapy notes? Yes, then this is the only item you may request on this authorization. You must submit another
authorization for other items below.
No, then you may check as many items below as you need.
Description: Date(s): Description: Date(s): Description: Date(s):
All PHI in medical record
Admission form
Dictation reports
Physician orders
Intake/outtake
Clinical test
Medication sheets
Operative information
Cath lab
Special test/therapy
Rhythm strips
Nursing information
Transfer forms
ER information
Labor/delivery summary
OB nursing assess
Postpartum flow sheet
Itemized bill:
UB-04:
Other:
Other:
I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, genetic information,
psychiatric, HIV testing, HIV results or AIDS information. _______________ (Initial)
I understand that:
1. I may refuse to sign this authorization and that it is strictly voluntary.
2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the
revocation. Further details may be found in the Notice of Privacy Practices.
4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal
privacy regulations and may be redisclosed.
5. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it.
6. I get a copy of this form after I sign it.
This authorization will expire on the following: (Fill in the Date or the Event but not both) Date: Event:
Section B: Is the request of PHI for the purpose of marketing and/or does it involve the sale of PHI? Yes No
If yes, the health plan or health care provider must complete Section B, otherwise skip to Section C.
Will the recipient receive financial remuneration in exchange for using or disclosing this information? Yes No
If yes, describe:
May the recipient of the PHI further exchange the information for financial remuneration? Yes No
Section C Signatures: I have read the above and authorize the disclosure of the protected health information as stated.
Signature of Patient/Patient’s Representative:
Date:
Print Name of Patient’s Representative:
Relationship to Patient:
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