Fillable Roi Medical Records Form

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Roi Medical Records Form

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The Roi Medical Records Form form is 2 pages long and contains:

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Country of origin: OTHERS
File type: PDF

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RESET
INSTRUCTIONS FOR MAKING AN E-DELIVERY
RECORDS REQUEST
You can make an e-request for records on our web-
page by going to the Emory Healthcare website at
www.emoryhealthcare.org and following these steps:
Click on the “Medical Records-Release of
Information” link at bottom right of page.
Click on the "Click Here to Request Records" link
under the "Electronic Request for Records" section
for the specific facility(s) you want to request records
from.
You will have the ability to request your records
electronically and receive them electronically.
Release of Information Policies
1. To properly assist in handling your request for medical information, please
completely fill out both pages of the authorization form and sign the patient fee
sheet.
2. Provided the medical record is complete and contains final copies of all
reports, documentation, and appropriate signatures, your request for
information will be submitted for processing within 24 to 48 hours after receipt
and delivered by mail or electronic (eDelivery) within 7 to 10 business days.
This policy is nullified for medical emergencies only.
3. All authorizations must be dated after discharge and signed by the patient,
unless he/she is a minor, deceased, physically and/or mentally impaired, or
has appointed a Durable Healthcare Power of Attorney or has a court
appointed guardian. Due to State and Federal laws, no exceptions will be
made.
4. Written authorization is required.
Release of Information Fees for Patients
Delivered in electronic format via CD, Flash Drive, or Electronic Website:
$6.50 flat fee. Plus sales tax and actual postage if mailed.
Delivered in paper format:
$0.07 per page. Plus, if applicable: $0.90 labor cost, $0.05 per page supply
cost, actual postage if mailed, and sales tax.
*Please Note: If the format of the original record is Hybrid (Part electronic &
Part paper), the fees will be a combination of both of the above.
Certification fee: $9.70
Radiology Film CD: $25 flat fee
Continued Patient Care: An Abstract of the record can be sent directly to a
healthcare provider at no cost.
**Please Note: In order to process requests for release of medical records
on its behalf, Emory Healthcare has contracted with a vendor that is
subject to HIPAA privacy and confidentiality requirements.
Your questions regarding Release of Information are welcomed. Please contact
the facility directly for any questions.
By signing below, I acknowledge that I have read the above procedures
regarding the release of medical records.
_____________________________ _________________
Patient/Representative Signature Date of Signature
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Roi Medical Records Form

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Completed 24 November 2021

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