Get (roi) Consent Form - Broward Health - Browardhealth

Filling out the (ROI) Consent Form is an important step in authorizing the release of your medical records while ensuring your rights are respected. This guide will help you understand each section and provide clear instructions for completing the form online.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the (ROI) Consent Form and open it in the editor.
2. Enter your medical record number and facility information in the designated fields to identify your records clearly.
3. Initial next to the appropriate classifications of information that you wish to authorize for release, such as drug and alcohol treatment, mental health, HIV/AIDS, or genetic information.
4. Fill in your personal information, including the patient's name, address, birth date, and telephone number. Make sure all details are accurate.
5. Clearly indicate whether you are the patient or a personal representative authorizing the release by circling the appropriate option.
6. Specify to whom you are releasing this information. Choose either yourself or another individual and fill in their name and address.
7. Select the method for receiving your records, either by picking up copies or receiving them by mail, and choose the format (paper form or encrypted CD).
8. State the purpose for which the information is being released. You may include specific details if necessary.
9. Indicate the type and amount of information to disclose. List any specific records you would like included or excluded.
10. Sign and date the form in the designated space. Ensure your signature is clear, and your printed name is included.
11. If applicable, provide a signature from a witness to authorize the release.
12. Once completed, save changes to the form, and you may opt to download, print, or share it as needed.

Complete your documents online to easily manage your medical information.