*ROICOR*
AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
(RELEASE OF INFORMATION)
*This request is to release medical records for:
Last Name ___________________________ First Name __________________ Middle___________ Date of Birth _______________
Maiden Name____________________ Last 4 of Social Security Number ______________ Telephone Number________________
Address (Street, City, State, ZIP Code) _____________________________________________________________________________
*Medical records release from: (Check a box for location)
Location
Daniel Drake
Center for Post-
Acute Care (DDC)
University of
Cincinnati
Medical Center
(UCMC)
University of
Cincinnati
Physician Office *
West Chester Hospital
(WCH)
Mailing Address
Medical Records Services
University of Cincinnati Medical Center
3188 Bellevue Avenue; ML0738
Cincinnati, OH 45219
UCP/MRO – Suite
2830 Victory Parkway
Cincinnati, Ohio 45206
Medical Records Services
West Chester Hospital
7777 University Drive, Suite A West
Chester, OH 45069
Phone Number
(513) 584-0444
(513) 245-3711
(513) 298-7750
Fax Number
(513) 584-0739
(844) 239-8077
(513) 298-7765
Email Address
Drake-medical-r[email protected]
UCMC-medical-recor[email protected]
WCH-medical-
records@uchealth.com
*If you selected UC Physician Office, please specify provider name, location or specialty: __________________________
*Medical records release to:
Name of Person or Organization: ________________________________________________________________________________
Address (Street, City, State, Zip Code)_____________________________________________________________________________
Recipient Phone #: _______________________________________ Recipient Fax #: ______________________________________
E-mail address: ____________________________________________ Send to MyChart __________
*Treatment Dates: From ______________________ To: _____________________
*Purpose of Request: Self/Personal Continuity of Care Legal Disability Insurance
The
following
information
to be
disclosed
(please
check):
Abstract
Discharge Summary
History and Physical examination
Consultations, Including psychiatric evaluations
Operative report or procedure reports
Emergency Department Record
Laboratory reports, including drug screens
Interdisciplinary records (progress notes)
Medication lists and documentation
Nursing notes
Physician orders
Other
___________________________
Sensitive
Information
I understand that the information in my records may include information relating to sexually transmitted diseases, Acquired
Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) infection. It may also include information about
behavioral or mental health services or treatment for alcohol and drug abuse.
Right to
Revoke
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do
so in writing via mailing or faxing to one of the locations listed above. I understand that revocation will not apply to information
that has already been released based on this authorization.
Expiration
Unless otherwise revoked, this authorization will expire on the following date or when the following event or condition occurs:
________________________ If I do not specify an expiration date, event, or condition, this authorization will expire in 1 year.
Re-disclosure
I understand that any disclosure of information carries with it the potential for re-disclosure and the information may not be
protected by federal confidentiality rules.
Other Rights
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. UC Health cannot
condition my treatment on the provision of this authorization. Research participation requires a separate authorization by the patient.
I understand that I may inspect or obtain a copy of the information to be used or disclosed. If I have any questions about disclosure of my
health information, I can contact the Health Information Management (HIM) Department by calling the number listed above.
*Date: ___________________ Time: _____________ *Print Name: _________________________________________________
Signature of Patient or Legal Representative *: ____________________________________________________________
If Signed by Legal Representative, relationship to patient ____________________________________________________
Legal representative must provide a copy of guardianship, Executor of Estate, or Power of Attorney (POA) documents
Copy to individual
UCH-ROI-01, Rev. 09/22
QuickTipsforRequestingYourMedicalRecord
Thereisachargeformedicalrecordscopies.Requestorswill
besentaprepayment
invoicefromourcopyingserviceMRO.Upondeterminationoftotalcostandonce
paymentisreceived,thechartswillbesent.
**Pleasenote:ThestateofKentuckyistheonlyplacethatoffers1FREEcopyofyour
chart,NOTOhio**
TheHealthInsurancePortabilityandAccountabilityAct(HIPAA)does not specify
a timeframe for requests from third parties with an authorization, although UC Health
will put forth every effort to provide records in a timely manner.
For“Continuityofcare”thereceivingcaregivertypicallyonlywantstoreceivean
“Abstract”ofkeyinformationfromthemedicalrecord.Thesame“Abstract”sentto ca
regiversalsoalmostalwaysmeetstheneedforindividualuse.
AMedicalRecord“Abstract”containsthefollowing:
DischargeSummary–thisdocumentisasummaryofthecare,treatment, and
services.
EmergencyDepartmentRecord
HistoryandPhysical–
thisformdetailsthehistoryofpresentillnessandany
relevantpasthistory
OperativeReports–thisreportdetailsthesurgeon’sfindings,technical
proceduresused,specimensremovedandpostoperativediagnosis
Consultation(s)Reports(s)–thisreportdocumentsthefindingsofa physician
requestedtoexamineapatient
Radiology,XͲray&Labreports
TheHealthInsurancePortabilityandAccountabilityAct(HIPAA)allowshealthcare
providers30daystoprocessrecords.UCHealthputsfortheveryefforttoprovide
recordsmoretimely,howeveroccasionallythefull30daysarerequiredtofulfillyour
request.
UCH-ROI-01, Rev. 09/22