醫療資訊開放授權, ROI

Authorization for Release of Medical Information, ROI

　　醫院有義務保護患者個人隱私，不得任意公開患者病歷，因此為便捷提供救援者（一般是指保險公司）取得患者詳細之病歷摘要，患者或家屬必須以書面授權醫院公開患者各項醫療資訊予特定人士，以下便是一般醫療資訊公開授權書條文範例：

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AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION

A. EXPLANATION

This authorization for disclosure of medical information is being requested from you to comply with the terms of the Confidentiality of Medical Information Act.

B. AUTHORIZATION

I hereby authorize ＯＯＯＯ（醫院名稱）

to disclose to ＸＸＸＸ（救援單位或人員名稱）, its officers, employees and/or affiliates my individually identifiable health information as described below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus ("HIV") and Acquired Immune Deficiency Syndrome ("AIDS"), mental illness (except for psychotherapy notes), chemical or alcohol dependency, laboratory test results, medical history, treatment, or any other such related information. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form and that if the recipient authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal and state privacy regulations.

Patient name: ＯＯＯ

Date of Birth:  YYYY/MM/DD

Date(s) of Service: _______________

Description of information to be released (check all that apply):

__ All information available
__ Face Sheet / __ Radiology Reports / __Radiology Films (Imaging Department) /
__ Discharge Summary / __ Laboratory Reports / __ Billing Records /
__ History & Physical / __ Pathology Reports / __Emergency Room /
__ Consultation Reports / __ Diagnostic Reports / __Operative Reports /
__ Other:

C. USER

The medical records and any other type of information released can be used only for the purpose of Insurance Coverage Verification. The information described herein will be sent to ＸＸＸＸ（救援單位或人員名稱）.

D. DURATION

I understand that I may revoke this consent at any time before the information has been released by submitting a written request. This revocation request must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.

This consent will expire in 180 days unless another date is written here: ____________________________

DATE:
SIGNATURE:
(RELATIONSHIP, IF OTHER THAN THE PATIENT)

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