Skip to Main ContentSkip to NavigationSkip to Footer

Release of Information

(ROI) Form

Authorization to Release Information

I, voluntarily authorize Saban Community Clinic to disclose my health information also known as Medical Records from the patient named below and released to the named recipient or organization of my choosing.

Please complete all sections of the form and use your legal name and information specified on your official identification card or letter

Patient Information

Recipient Information

Please provide the full name of the recipient, personal representative or organization you want your records sent to. Type “Self” if the records are to go to you:

Select the following that apply:

What is the purpose for requesting records? (select one)

Please choose what you want to release from your medical record:

How do you prefer to receive the records?

By signing this Authorization for Release of Information you agree to the following terms:

Health information released by this authorization (except for Alcohol and Drug Abuse) may be subject to release by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA), Privacy Rule and the Privacy Act of 1974.

Copies of medical records not picked-up within 30 business days of the date of this request date will be destroyed and a new Authorization to Request for Information may need to be submitted again.

I understand that I may revoke this authorization in writing by submitting the request at any time to Saban Community Clinic’s Medical Records Department, otherwise this authorization is valid for 1 full year from the date it was signed.

This release of authorization will expire on (you have the option to change the expiration date)

Please upload a valid form of identification with photo ID. E.g. Drivers License, State Issued ID, Military ID, etc. We accept the following image formats JPEG, JPG, PNG, GIF, and TIFF. Max file size is 10 Megabytes (MB).

Please use your mouse or touchpad to sign your name in the grey section below, then click “Submit Form” to submit your request.