Release of Information (ROI) Forms

Please download, complete and sign the form and send to Health Information Management (HIM). To complete them on your computer, download and save the PDF, then open with Adobe Reader. (Learn how to complete an authorization form.)

• Accounting of Disclosure: Complete this form to request an accounting of disclosure(s) of your protected health information.
• Amendment of Protected Health Information Request: Submit this form to request an amendment to your protected health information.
• Distributee Certification Form: Use this form when an executor/administrator of an estate has not yet been chosen.
• OCA Form 960 - English (OCA Form 960 - Spanish): Submit this Office for Civil Rights form to request information relating to HIV/AIDS, mental health and drug/alcohol abuse.
• Patient Access Request Form: Request access to or copies of your UR Medicine patient care records.
• SH 48 Release Authorization Form - English (SH 48 Release Authorization Form - Spanish): Submit this form to request information relating to medical, mental health and drug/alcohol abuse. If you are an attorney and requesting HIV/AIDS information, please use OCA 960 Form.
• Attestation for Disclosure of PHI – Reproductive Healthcare: This form is to be use for Health Oversight activities, judicial or administrative proceedings, law enforcement, or disclosures to coroners or medical examiners when a patient authorization is not used.

Care Everywhere^®

• Care Everywhere Agreement ("Opt-in"): Complete this form to opt-in to sharing your personal health information with other health care organizations through Care Everywhere.
• Care Everywhere Refusal ("Opt-out"): Complete this form to opt-out of sharing your personal health information through Care Everywhere.