Release of Information (ROI) Form

PLP acknowledges that Privacy & Security is part of dignified care, which this organization takes very seriously. Therefore, we are opting in to certain security measures that will protect patients data from unauthorized access. An ROI (Release of Information) gives your provider permission to share specific information with PLP. This information is required to apply for financial assistance.

PATIENT AUTHORIZATION FOR USE & DISCLOSURE (RELEASE OF INFORMATION)

Patient Name(Required)

First Last

Patient Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Patient Email(Required)

Facility Name(Required)

I authorize this Facility to use or disclose my health information as described below.

1. TYPE OF INFORMATION - Any patient that wants to be considered for Pink Lemonade Project’s financial assistance programs must release their diagnosis, treatment plan and financial portrait. Please check below that you agree to these terms.

Please select:(Required)

Diagnosis, Treatment Plan and Financial Portrait of the Individual’s needs *

History of Financial Aid

Social Services needs

Other:

*Required for enrollment in Pink Lemonade Project programs

Diagnosis, Treatment Plan, and Financial Portrait of Individual Needs must be checked in order for you to enroll in Pink Lemonade Project programs.

If Other, describe as specifically as possible:(Required)

2. RECEIPT OF INFORMATION - The information identified above may be used by, or disclosed to, the following individual(s) or organization(s):

Organization Name

Organization Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION

3. Purpose of use/disclosure - This information described on the previous page will be used for the following purpose(s):

Purpose of use(Required)

Initiated at the request of the provider

Initiated at the request of the patient

Enrollment in PLP Programs

Other:

If Other, please describe:(Required)

4. Requested Restrictions:

PATIENT AUTHORIZATION & SIGNATURES

Pink Lemonade Project (PLP) cares about the patient’s privacy and protects how we use your information. By signing this form, you understand and agree you have discussed this program with your provider and you are aware that PLP is not HIPAA compliant. PLP commits to the confidentiality of patient information.

5. I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the HIPAA Privacy Rule may no longer protect the information.

6. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to a licensed Facility staff member. I understand that the revocation will not apply to information that has already been released in response to this authorization.

7. This authorization will expire upon ceasing healthcare services with the signing provider unless you specify differently. (Insert date or event):

Insert Date or Event If Applicable:

8. I understand that my healthcare provider will not condition the provision of treatment or payment on the provision of this authorization for services to Pink Lemonade Project. I also understand that Pink Lemonade Project is not a healthcare provider and cannot enroll me in PLP services without the required information.

Signature(Required)

Please use your mouse, finger or stylus to sign your name in this box.

Type Name(Required)

Title

If this is the Patient's personal representative, then please include your title (e.g., Guardian, Executor of Estate, Health Care Power of Attorney).

Date(Required)