Get Where Is Release Of Information (roi) - Baylor Scott & White Health

This guide provides a comprehensive overview of how to complete the Where Is Release Of Information (ROI) - Baylor Scott & White Health form online. By following these instructions, users will be able to navigate the process effectively and ensure their health information is released as needed.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the document and open it for editing.
2. Enter the patient's medical record number in the space provided at the top of the form.
3. Fill in the patient's name and date of birth in the designated fields to identify the individual whose information is being requested.
4. Provide the full address, including city, state, and ZIP code, as well as a contact phone number and email address of the patient.
5. In the 'Release Information From' section, specify the original provider or facility, including the name, address, phone number, and fax number.
6. In the 'Release Information To' section, fill in the details of the individual or facility receiving the information, including their contact details.
7. Select the specific information that you wish to be released by checking the appropriate boxes under 'Information to be Released.'
8. Indicate the service dates for which records are requested by entering the 'From' and 'To' dates.
9. Choose the purpose for which the information will be used from the options provided.
10. If the records include sensitive information, check the respective box to confirm consent for its disclosure.
11. Select the preferred release format (paper, CD/DVD) and method of release (mail, pick up, fax, email, or portal).
12. Carefully read the authorization statement and sign the form. Include the date and relationship to the patient if applicable.
13. Once the form is completely filled out, review all information for accuracy before submitting it online.
14. Users can choose to save changes, download, print, or share the completed form as necessary.

Begin your online request for the release of information today.