ROI

By completing this form, you authorize the Nashville CARES Clinic to release your medical records to another provider or practice.

All fields must be completed with appropriate information for records to be sent.

By filling out and signing this form, you understand that:
• This authorization is valid for one (1) year, and you may cancel this permission at any time. You must cancel in writing and send or deliver cancellation to releasing facility or practice named herein. Any cancellation will apply only to information not yet released by facility or practice.
• This is a full release including information related to behavioral/mental health, drug and alcohol abuse treatment (in compliance with 42 CFR Part 2), genetic information, HIV/AIDS, and other sexually transmitted diseases.
• Once your health information is released, the recipient may disclose or share your information with others and your information may no longer be protected by federal and state privacy protections.
• Refusing to sign this form will not prevent your ability to get treatment, payment, enrollment in health plan, or eligibility for benefits.
• The Nashville CARES Clinic will not share or use your health information without your permission other than by ways listed in the Nashville CARES Clinic Notice of Privacy Practices or as required by law. The Notice of Privacy Practices is available at NashvilleCARES.org
• You will receive a copy upon completion.