RELEASE OF INFORMATION (ROI)

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

Please correct the errors described below.

I AUTHORIZE THE FOLLOWING ORGANIZATION TO DISCLOSE MY PHI TO GI ASSOCIATES:

GI ASSOCIATES IS AUTHORIZED TO DISCLOSE MY PHI TO:

TYPE OF INFORMATION TO BE RELEASED

Purpose or need for disclosure:

Information may be released electronically: (Please check which apply)

(NOT recommended by GIA, email is not encrypted)

(this method is not encrypted)

My signature below confirms I understand: I have the right to a copy of this authorization. I may revoke this authorization at any time by written notice to the organization I authorized to use or disclose my information, but if I do so it will not impact any use of disclosure that has taken place before the revocation. Treatment, payment, enrollment in a health plan or eligibility for benefits cannot be conditioned on my decision whether to sign this authorization except for certain research-related treatment, or if the purpose of this authorization is to create information for a third party (such as an independent medical examination), or in connection with an insurance dispute if this authorization is a condition to obtain insurance coverage. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal law.

I authorize the use and/or disclosure of my medical information in accordance with the conditions listed above. I understand there may be charges for copies, in accordance with state law.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

If signed by person other than patient, state relationship and authority to do so.

Your information will be encrypted.

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