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URMC / Health Information Management / Release of Information (ROI) Forms
 

Release of Information (ROI) Forms

In order to use the fill-in functionality for the specific form, you will need to save the PDF and open the form in Adobe Reader.

Complete this form if the executor/administrator of the estate has not yet been chosen.  Mail or fax to HIM ROI (sidebar).

Complete this form to request records for Strong Memorial Hospital.  See above for fill-in functionality. Once completed, print, sign and date at the bottom of the form.  Mail or fax to HIM ROI (top of form).

Complete this form to request records for Highland Hospital.  See above for fill-in functionality.  Once completed, print, sign and date at the bottom of the form.  Mail or fax to HIM ROI (top of form).

Complete this form to request records for F.F. Thompson Hospital.  See above for fill-in functionality.  Once completed, print, sign and date at the bottom of the form.  Mail or fax to HIM ROI (top of form).

Complete this form to request an amendment of your protected health information for Strong Memorial Hospital.  Mail or fax to HIM ROI (sidebar).

Complete this form to request your own records for Strong Memorial Hospital.  See above for fill-in functionality.  Once completed, print, sign and date.  Mail or fax to HIM ROI (top of form).

Office for Civil Rights form should be completed when requesting information regarding HIV/AIDS.  See above for fill-in functionality.  Once completed, print, sign and date.  Mail or fax to HIM ROI (sidebar).

Complete this form to request an amendment of your protected health information for Highland Hospital.  Mail or fax to HIM ROI (sidebar).

Complete this form to request your own records for Highland Hospital.  See above for fill-in functionality.  Once completed, print, sign and date.  Mail or fax to HIM ROI (top of form).

Complete this form to request an amendment of your protected health information for F.F. Thompson Hospital.  Mail or fax to HIM ROI (sidebar).

Complete this form to request your own records for F.F. Thompson Hospital.  See above for fill-in functionality.  Once completed, print, sign and date.  Mail or fax to HIM ROI (top of form).

Complete this form to request an accounting of disclosure of your PHI.  Mail or fax to HIM ROI (sidebar).

Complete this form to opt-in to the Care Everywhere Agreement.  Mail or fax to HIM ROI (sidebar).

Complete this form to opt-out of the Care Everywhere Agreement.  Mail or fax to HIM ROI (sidebar).