Release of Information (ROI) Forms
ROI Forms
Please see the forms offered by the Health Information Management Department team below that can be utilized to request medical records. For additional help on requesting medical records, see Requesting Medical Records.
Patient Access Request Form
Patients and/or patient family members requesting personal access to or copies of a UR Medicine and Affiliate patient care records. For patient and family use only. Attorneys, please use the OCA or SH 48 forms below.
SH 48 Release Authorization Form - English (SH 48 Release Authorization Form - Spanish)
Submit this form to request information relating to medical, mental health and drug/alcohol abuse. If you are requesting records that may contain HIV/AIDS information, please use OCA 960 Form in order to obtain records.
OCA Form 960 - English (OCA Form 960 - Spanish)
Submit this Office for Civil Rights form to request information relating to HIV/AIDS, mental health and drug/alcohol abuse.
Distributee Certification Form (Notarized Next of Kin Document)
Use this form when an executor/administrator of an estate has not yet been chosen. Please be sure to submit to the Release of Information department for processing with a request for medical records and a copy of the patient’s death certificate.
Request for Record Change/Amendment
Submit this form to request an amendment to your protected health information. Please be advised that the Release of Information team suggests that patients discuss any inaccuracies found within their medical records with the providers whom entered the information. Many areas of your record can be updated/revised at the time of any UR Medicine and Affiliate providers office appointment; these include but are not limited to:
- Medication List
- Problem List
- Personal, Medical, Social, Family, and Economic-social Histories
Requests for an amendment to a patient's medical record is not a guarantee that the records will reflect as requested. Medical providers do have the authority to deny amendment requests if the information requested was not authored by a UR Medicine and Affiliate provider or the information was true and accurate at the time of treatment. Each request is handled on a case-by-case basis and reviewed by both the Health Information Management Department and the patient(s) treatment providers. It is imperative to note that the Health Information Management Department is not responsible for making any corrections/changes to a patient's medical record as we are only the acting liaison between patients and treatment providers during an active amendment request. Requests can take up to 60 business days and include an optional 30-day extension. Each request received is assigned to a Release of Information specialist to ensure communication is as direct and fluent as possible during the processing period.
Please contact the Health Information Management Department directly to inquire about any currently pending requests.
Accounting of Disclosure
Complete this form to request an accounting of disclosure(s) of your protected health information. Please be advised that a patient accounting of disclosure report does not show whom within the UR Medicine and Affiliate system accessed a patient's medical record. If concerns regarding access into a patient's medical record arise; please contact our HIPAA Hotline Directly at: (585) 756-8888.
A valid authorization is required for most outside (non-patient) requesters and must be written in plain language (or be accompanied with a translated copy) containing the following elements:
- A description of the information to be used or disclosed. This can either be specific dates of service, an illness, a treating department, and/or provider.
- The identification of the person authorized to make the requested use or disclosure. (The name of the entity/person that will be releasing the records.)
- The name of the person to whom the entity may make the requested use or disclosure. (The name of the entity/person that will receive the records. Please provide full contact information: name, mailing address, phone, fax.)
- A description of each purpose of the requested use or disclosure. The statement “at the request of the individual” is a sufficient description of the purpose when an individual initiates the authorization and does not elect to provide a statement of the purpose.
- An expiration date or an event that triggers expiration. The statement “end of the research study,” “none,” or similar language is sufficient if the authorization is for research, including for the creation and maintenance of a research database or research repository. It is important to note that having a future date listed as the authorization expiration may not release records created up to the listed expiration date. For Release of Information to be able to release records created in the future, the statement "to include future and/or subsequent records" will need to be included.
- A statement that the individual has a right to revoke the authorization, with exceptions identified, and a description of how revocation may be done.
- A statement that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer is protected by this rule.
- Signature of the individual and date. Please be advised that a computer typed signature is valid ONLY when additional identifiers are validated. An additional two identifiers are needed to accept an electronic signature: email, mailing address, phone number, or next of kin information.
- If the authorization is signed by a personal representative of the individual, a description of the representative’s authority to act for the individual.
- You may request to release a copy of your medical records to another provider through MyChart (access the menu and select Request Medical Record Release located under the Sharing subsection).
Be advised the Health Information Management Department is unable to monitor the release of information and/or records done so via UR Medicine and Affiliates offices directly.
All patients within the UR Medicine and Affiliate care system are automatically enrolled within the Care Everywhere sharing link through the Epic medical record system.
To opt-out of this, please complete the Care Everywhere opt-out form below and submit to your medical providers office or the Health Information Management Department directly.
- Care Everywhere Agreement ("Opt-in"): Complete this form to opt-in to sharing your personal health information with other health care organizations through Care Everywhere.
- Care Everywhere Refusal ("Opt-out"): Complete this form to opt-out of sharing your personal health information through Care Everywhere.
Be advised the Health Information Management Department is unable to monitor the release of information and/or records done so via the RRHIO system.
All patient inquiries regarding the RRHIO consent should be directed to the RRHIO directly as this is a separate system outside of UR Medicine and Affiliates.
Please contact the RRHIO at: 1-877-865-7446 to WITHDRAW consent to the automatic sharing of information through the RRHIO network.
More information regarding the RRHIO can be found at: www.RochesterRHIO.org