Review all of the ROI forms.In your review, be sure to specifically address the forms' compliance with HIPAA as it relates to psychotherapy notes, mental health and HIV. Evaluate each form to determine if they meet the HIPPAA requirements. Submit your critique.

Patient Request for Health Information Patient Information (Please Print) First Name: Middle Initial: Last Name: Name at Time of Treatment (if different than above): Date of Birth (MM/DD/YYYY): Phone E-mail (optional): Street Address: City State: Zip: What records do you want? (Check appropriate boxes below): Billing Records Date(s) of Service: through Discharge Summary Emergency Room Records Operative/Procedure Reports Test Results (X-Rays, Lab/Pathology Results) Please specify: Other (Immunization Records, Medication Lists) Please specify: How would you like your records delivered? Paper Home Delivery In-Person Pickup Electronic (Email, USB, CD, Portal, Other) Please specify: Where do you want the information sent? (Fill in boxes below): ORGANIZATION NAME should provide my records to: Self Personal Representative (indicated below) Recipient Name: Recipient Phone: Other (Immunization Records, Medication Lists) Please specify: How would you like your records delivered? Paper Home Delivery In-Person Pickup Electronic (Email, USB, CD, Portal, Other) Please specify: Where do you want the information sent? (Fill in boxes below): ORGANIZATION NAME should provide my records to: Self Personal Representative (indicated below) Recipient Name: Recipient Phone: Recipient Mailing Address: Recipient Fax: Recipient E-mail (if applicable): Please print your name and sign below: Name of Patient or Personal Representative (please print) Relationship (please print) Signature of Patient or Personal Representative Date/Time Please return completed form to: E-mail: Fax: Questions? ORGANIZATION NAME recognizes a patient's right under HIPAA to access copies of his/her health information. There may be charges associated with processing a request and producing requested records. NEW YORK STATE DEPARTMENT OF HEALTH Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS-related Information Date of Birth Patient Identification Number Patient Name Patient Address I. or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDS-RELATED INFORMATION only if I place my initials on the appropriate line in item 8. In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 8, I specifically authorize release of such information to the person(s) indicated in Item 6. 2. With some exceptions, health information once disclosed may be re-disclosed by the recipient. If I am authorizing the release of HIV/AIDS-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from re-disclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDS-related information, I may contact the New York State Division of Human Rights at 1-888-392-3644. This agency is responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the provider listed below in Item 5. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent. 5. Name and Address of Provider or Entity to Release this Information: 6. Name and Address of Person(s) to Whom this Information Will Be Disclosed: 7. Purpose for Release of Information: until 8. Unless previously revoked by me, the specific information below may be disclosed from: All health information (written and oral), except: INSERT START DATE INSERT EXPIRATION DATE OR EVENT 5. Name and Address of Provider or Entity to Release this Information: 6. Name and Address of Person(s) to Whom this Information Will Be Disclosed: 7. Purpose for Release of Information: until 8. Unless previously revoked by me, the specific information below may be disclosed from: All health information (written and oral), except: INSERT START DATE INSERT EXPIRATION DATE OR EVENT Information to be Disclosed Initials For the following to be included indicate the specific information to be disclosed and initial below. Records from alcohol/drug treatment programs Clinical records from mental health programs* HIV/AIDS-related Information 9. If not the patient, name of person signing form: 10. Authority to sign on behalf of patient: All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form. SIGNATURE OF PATIENT OR REPRESENTATIVE AUTHORIZED BY LAW DATE Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided to the patient and/or the patient's authorized representative. STAFF PERSON'S NAME AND TITLE SIGNATURE DATE This form may be used in place of DOH-2557 and has been approved by the NYS Office of Mental Health and NYS Office of Alcoholism and Substance Abuse Services to permit release of health information. However, this form does not require health care providers to release health information. Alcohol/drug treatment-related information or confidential HIV-related information released through this form must be Zip: 111 17 Avenue East Alexandria Clinic Heartland Orthopedics Alexandria, MN 56308 610 30 Ave West 111 17 Ave East, Suite 101 Phone: 320-762-1511 Alexandria, MN 56308 Alexandria, MN 56308 Phone: 320-763-5123 Phone: 320-762-1144 ALOMERE Fa 220-7626127 Fax: 320-763-7883 Fax: 320-762-1935 HEALTH AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION Here for Name: Date of Birth: Patient Previous Name: Phone Number: Information: Street Address: City: State: Zip: Internal Use: MRNA This will Organization/Name: Authorize: (Who has the Address: Phone Number: merced information you would City: State: Fax Number: To Release Organization/Name: Records To: Address: Phone Number: (Where do you want the information sent?) City: State: Zip: Fax Number: Relationship to Patient (if any) Method of Mail Fax in Person Picture I Will Be Required Sending: (If someone other than you will be picking up records, print their name here:) ASAP Request Date Needed By: Format of Records: Paper Electronic MyChart what is Mychart Rater tas headinycar.com.cn ianetnearanate Information to be Dates of Service: From: To: Disclosed: Operative Reports Nursing Notes (Indicate only the Discharge Summary Emergency Room Reports Information you are Consultation Reports Rehabilitation (PT/OT/ST) authoriting to be History and Physical Reports X-ray/Radiology Reports__X-ray Films released) Laboratory/Pathology Reports _EKG/Echo/Cardiology Progress Notes Medication Records Other (Specify) Billing *If no dates of service are requested, one year of health information will be provided. Special Disclosure: HIV/AIDS STD Chemical Dependency Mental Health Psychotherapy Notes equire separate Reason for Continuing Care Legal/Attorney Insurance Claim Personal use Relocating Disclosure: Disability Patient Review Billing Purpose Referral other I understandi may revelion this authorization by written request at any time to the address listed at the top of this form. I understand that the vocation will not apply to information that has already been released in response to this authorization Revocation: (period of time, foresampled This authorization will automatically expire ane year from the date of my signatura, ar weke month from the date of my store specified here. The spiration period noted here may become one year any in certain situation specified in Minnesota statute 144.33 Safor ease to provider in comection with current treatment for release for purposes of payment clima, fraud investigation or quality of care for release to an external researchersely for purposes of medical or scientific research I understand that the organisation receiving the information will not condition treatment, payment, enrolment or elibility for benefits an whether in the commentform I understand that once information is released pursuant to this authorization, this facility cannot prevent the re-disclosure of the information to in the third party and may no longer be protected by Federal or state privacy laws. I understand this authoritation must be filled out completely, signed and dated in order to be considered valid. A fax or photocopy that has not Additional buen altered will be considered a valid as an original. Information: As noted above, I understand may revoke this authorization by written requirit at any time to the authorized address listed above I understand there may be arrival and copy charge acted with the release 00 Patient Request for Health Information Patient Information (Please Print) First Name: Middle Initial: Last Name: Name at Time of Treatment (if different than above): Date of Birth (MM/DD/YYYY): Phone E-mail (optional): Street Address: City State: Zip: What records do you want? (Check appropriate boxes below): Billing Records Date(s) of Service: through Discharge Summary Emergency Room Records Operative/Procedure Reports Test Results (X-Rays, Lab/Pathology Results) Please specify: Other (Immunization Records, Medication Lists) Please specify: How would you like your records delivered? Paper Home Delivery In-Person Pickup Electronic (Email, USB, CD, Portal, Other) Please specify: Where do you want the information sent? (Fill in boxes below): ORGANIZATION NAME should provide my records to: Self Personal Representative (indicated below) Recipient Name: Recipient Phone: Other (Immunization Records, Medication Lists) Please specify: How would you like your records delivered? Paper Home Delivery In-Person Pickup Electronic (Email, USB, CD, Portal, Other) Please specify: Where do you want the information sent? (Fill in boxes below): ORGANIZATION NAME should provide my records to: Self Personal Representative (indicated below) Recipient Name: Recipient Phone: Recipient Mailing Address: Recipient Fax: Recipient E-mail (if applicable): Please print your name and sign below: Name of Patient or Personal Representative (please print) Relationship (please print) Signature of Patient or Personal Representative Date/Time Please return completed form to: E-mail: Fax: Questions? ORGANIZATION NAME recognizes a patient's right under HIPAA to access copies of his/her health information. There may be charges associated with processing a request and producing requested records. NEW YORK STATE DEPARTMENT OF HEALTH Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS-related Information Date of Birth Patient Identification Number Patient Name Patient Address I. or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDS-RELATED INFORMATION only if I place my initials on the appropriate line in item 8. In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 8, I specifically authorize release of such information to the person(s) indicated in Item 6. 2. With some exceptions, health information once disclosed may be re-disclosed by the recipient. If I am authorizing the release of HIV/AIDS-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from re-disclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDS-related information, I may contact the New York State Division of Human Rights at 1-888-392-3644. This agency is responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the provider listed below in Item 5. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent. 5. Name and Address of Provider or Entity to Release this Information: 6. Name and Address of Person(s) to Whom this Information Will Be Disclosed: 7. Purpose for Release of Information: until 8. Unless previously revoked by me, the specific information below may be disclosed from: All health information (written and oral), except: INSERT START DATE INSERT EXPIRATION DATE OR EVENT 5. Name and Address of Provider or Entity to Release this Information: 6. Name and Address of Person(s) to Whom this Information Will Be Disclosed: 7. Purpose for Release of Information: until 8. Unless previously revoked by me, the specific information below may be disclosed from: All health information (written and oral), except: INSERT START DATE INSERT EXPIRATION DATE OR EVENT Information to be Disclosed Initials For the following to be included indicate the specific information to be disclosed and initial below. Records from alcohol/drug treatment programs Clinical records from mental health programs* HIV/AIDS-related Information 9. If not the patient, name of person signing form: 10. Authority to sign on behalf of patient: All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form. SIGNATURE OF PATIENT OR REPRESENTATIVE AUTHORIZED BY LAW DATE Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided to the patient and/or the patient's authorized representative. STAFF PERSON'S NAME AND TITLE SIGNATURE DATE This form may be used in place of DOH-2557 and has been approved by the NYS Office of Mental Health and NYS Office of Alcoholism and Substance Abuse Services to permit release of health information. However, this form does not require health care providers to release health information. Alcohol/drug treatment-related information or confidential HIV-related information released through this form must be Zip: 111 17 Avenue East Alexandria Clinic Heartland Orthopedics Alexandria, MN 56308 610 30 Ave West 111 17 Ave East, Suite 101 Phone: 320-762-1511 Alexandria, MN 56308 Alexandria, MN 56308 Phone: 320-763-5123 Phone: 320-762-1144 ALOMERE Fa 220-7626127 Fax: 320-763-7883 Fax: 320-762-1935 HEALTH AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION Here for Name: Date of Birth: Patient Previous Name: Phone Number: Information: Street Address: City: State: Zip: Internal Use: MRNA This will Organization/Name: Authorize: (Who has the Address: Phone Number: merced information you would City: State: Fax Number: To Release Organization/Name: Records To: Address: Phone Number: (Where do you want the information sent?) City: State: Zip: Fax Number: Relationship to Patient (if any) Method of Mail Fax in Person Picture I Will Be Required Sending: (If someone other than you will be picking up records, print their name here:) ASAP Request Date Needed By: Format of Records: Paper Electronic MyChart what is Mychart Rater tas headinycar.com.cn ianetnearanate Information to be Dates of Service: From: To: Disclosed: Operative Reports Nursing Notes (Indicate only the Discharge Summary Emergency Room Reports Information you are Consultation Reports Rehabilitation (PT/OT/ST) authoriting to be History and Physical Reports X-ray/Radiology Reports__X-ray Films released) Laboratory/Pathology Reports _EKG/Echo/Cardiology Progress Notes Medication Records Other (Specify) Billing *If no dates of service are requested, one year of health information will be provided. Special Disclosure: HIV/AIDS STD Chemical Dependency Mental Health Psychotherapy Notes equire separate Reason for Continuing Care Legal/Attorney Insurance Claim Personal use Relocating Disclosure: Disability Patient Review Billing Purpose Referral other I understandi may revelion this authorization by written request at any time to the address listed at the top of this form. I understand that the vocation will not apply to information that has already been released in response to this authorization Revocation: (period of time, foresampled This authorization will automatically expire ane year from the date of my signatura, ar weke month from the date of my store specified here. The spiration period noted here may become one year any in certain situation specified in Minnesota statute 144.33 Safor ease to provider in comection with current treatment for release for purposes of payment clima, fraud investigation or quality of care for release to an external researchersely for purposes of medical or scientific research I understand that the organisation receiving the information will not condition treatment, payment, enrolment or elibility for benefits an whether in the commentform I understand that once information is released pursuant to this authorization, this facility cannot prevent the re-disclosure of the information to in the third party and may no longer be protected by Federal or state privacy laws. I understand this authoritation must be filled out completely, signed and dated in order to be considered valid. A fax or photocopy that has not Additional buen altered will be considered a valid as an original. Information: As noted above, I understand may revoke this authorization by written requirit at any time to the authorized address listed above I understand there may be arrival and copy charge acted with the release 00