MAT.ROI

Patient Name*

First NameLast Name

Date of Birth*

Date

UniqueID*

Please choose 1 option:

SpecialistsMAT is requesting the patient's outside medical records to be sent to our providersThe patient is requesting that SpecialistsMAT send records to an outside providerThe patient gives SpecialistsMAT the authority to speak to an outside provider for the purpose of coordination of care and the treatment plan

Which individuals/ institutions has the patient given consent for our office to coordinate care with?*

Name of Facility/ Provider Where Request is Sent To*

Prior to completing this form, please add either the facility/ provider email or the facility fax #.

EMAIL

Facility FAX #

Provider

Does today's ROI concern benzodiazepines and / or stimulants prescribed by another provider?*

YESNO

Special Instructions/ Information Requested

Purpose of Disclosure

Date

I authorize the above named or receiving facility to release or disclose to Specialists/ MAT all of my medical records, including any specially protected records, such as those relating to psychological or psychiatric impairments, substance use disorders, and medical or surgical treatments.

I authorize Specialists/ MAT to coordinate care with professionals and health care delivery systems as clinically appropriate. Coordination of care may include treatment updates, psychotherapy notes, and laboratory findings.

If you do not want certain portions of your medical records released, please read this section carefully and identify the information you do not want released. Otherwise, your records will be released as specified above.

I understand that I may revoke the authorization at any time prior to the expiration date or event, but that my revocation will not have any effect on actions taken by Specialists/ MAT or its physicians, employees or agents before they received my revocation. Should I desire to revoke this authorization, I must send written notice to Specialists/ MAT.

I understand that I am not required to sign this authorization. Specialists/ MAT or its physicians, employees will not condition treatment, payment, enrollment or eligibility for benefits on whether I provide this Authorization.

I understand that my records may be subject to disclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that this Authorization does not limit Specialists/ MAT or its physicians, employees its physicians’, employees’ or agents’ ability to use or disclose my information for treatment, payment, or health care operations, or as otherwise permitted by law.

This release of information expires in 1 year after signature date.

Type of consent:*

Verbal/ patient was seen virtuallyIn-person

Patient/ Authorized Representative Signature Signature*

Relationship to Patient if Not Signed by Patient

Witness Signature Signature*

Louisville Office: 3310 Ruckriegel Drive, Louisville, KY 40299

Elizabethtown Office: 110 Chase Way, Suite #2, Elizabethtown, KY 42701

ph.: 502 212 0071

ALL MEDICAL RECORDS SHOULD BE SENT BY FAX TO: (502) 996-8359

Release of Information