• Patient Record Request Form

  • Please select the statement that best describes you:

  • Release of Information (ROI)

  • A valid Release of Information (ROI) is required for all record requests. Please select the statement that is most applicable:*
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  • We need more information...

    Unfortunately, you are not able to complete a record request without a valid ROI.

    Please direct the patient to fill out an ROI for you. They can do this by contacting their primary center location.

  • Patient Record Request Form

    Fax #: 513.547.4109
  • Patient Date of Birth*
     - -
  • Submission Date
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Information to be disclosed: I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), mental health and substance use. I authorize the release or disclose of the records below

  • Or only the following specific types of records (check each category that applies):
  • Date of information to be disclosed:*
  • Start Date*
     - -
  • End Date*
     - -

  • Consent for the Release of Information under 42 C.F.R. Part 2 Confidentiality of Substance Use Disorder Patient Records

  • Purpose of disclosure:*

  • I understand that my substance use disorder patient records are protected under federal regulations 42 C.F.R. Part 2 Confidentiality of Substance Use Disorder and HIPAA. These records cannot be redisclosed without my written consent.

  • Clear

  • This Record Request Form is valid for one-time use.

    IMPORTANT: This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2 and HIPAA). BrightView has no responsibility for how you redisclose these records once they are in your possession.

  • Date signed
     / /
  • Date signed:
     / /

  • Notice of Federal Requirements Regarding the Confidentiality of Substance Use Disorder Patient Information


    The confidentiality of substance use disorder patient records maintained by this program is protected by federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless:

    1. The patient consents in writing; or

    2. The disclosure is allowed by a court order accompanied by a subpoena;or

    3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation; or

    4. The patient commits or threatens to commit a crime either at the program or against any person who works for the program.

    Violation of federal law and regulations by a program is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs.

    Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

    The releases of information will remain active and valid for one year from the date of signature OR until 90 days after discharge (whichever comes first) OR until a specific date, event, or condition as listed on the form. There are two ways to revoke a release of information: Come in to the BrightView facility where you were scheduled to receive treatment and sign the revocation, or fax in a written statement with your name, signature, date and release(s) you would like to be revoked.

    (See U.S.C. 290dd-2 for federal law and 42 C.F.R. Part 2 for federal regulations governing Confidentiality of Substance Use Disorder Patient Records)

     

  • For third party requests, BrightView will determine if there's an existing ROI and will communicate with the given contact for any updates.

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