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REFILLs
RElease of info
RELEASE OF INFORMATION (ROI)
WE TAKE CONFIDENTIALITY SERIOUSLy.
During Covid-19, we are offering patients the option to electronically request Release of information (ROI) to and from other providers (I.E. THERAPISTS, PRIMARY CARE PHYSICIANS).
please fill out the form below and electronically sign, to allow us permission to share medical information with other providers.
Please fill out ALL SECTIONS and then hit
"SUBMIT RELEASE OF INFORMATION (ROI) REQUEST" button.
* Patient's date of birth
* Name of Provider at our clinic
Isadora Fox, PMHNP
Justin Cullers, PMHNP
Michelle Magid, MD
* I am allowing the following ROI between providers
All records/communication
Verbal communication only
Exchange of Medical Records only
* Today's date
* I understand that by checking this box, I am electronically signing the request for Release of Information (ROI) between Austin PsychCare and the providers I have listed above. I understand that this ROI is good for 1 year from the signed date, unless otherwise specified.
SUBMIT Release of information (ROI) REQUEST >
