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Phone: (970) 494-4200 Fax: (970) 613-4475 (medical records) 1250 N

Phone: (970) 494-4200 Fax: (970) 613-4475 (medical records) 1250 N-2026

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4.8 out of 5

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The document is a Release of Information (ROI) form from SummitStone Health Partners, allowing clients to authorize the exchange of their medical information with specified individuals or organizations. It outlines the purpose of disclosure, types of information that can be released, and includes consent for sharing sensitive health data under federal regulations. The form also provides instructions for revoking consent and specifies that it remains valid for two years.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Client Name and Date of Birth in the designated fields at the top of the form.
Fill in the Name or Organization Name, Relationship to Client, and Address/Email of the recipient for information exchange.
Specify the purpose of disclosure by checking the appropriate boxes that apply to your situation.
Select any items you wish to release by checking the corresponding boxes under 'Please check any items below to release the following information.'
Sign and date at the bottom of the form. If applicable, ensure a parent/guardian or authorized representative signs as well.
If you need to revoke permission later, complete the Authorization to Revoke Release section at the end of the document.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (102 Votes)

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Is patient ID the same as MRN?

Textbook Expert-Verified⬈(opens in a new tab) A patient identification number (patient ID) and a medical record number (MRN) are not the same. The patient ID identifies an individual across healthcare visits, while the MRN identifies a patients medical record within a specific facility.

How to see mrn number?

If you lose your MRN number, you can retrieve it online via the official healthcare portals: Dubai Health Authority (DHA): Visit the DHAs online portal or use their DHA App to access your MRN. Simply log in using your Emirates ID or passport details, and your MRN will be displayed along with your medical history.

What is SummitStone Fort Collins?

SummitStone helps people transform their lives by providing mental health and substance use services that truly work. We know people can and do recover from mental health challenges. Since 1957, weve been the largest nonprofit mental health provider in Larimer County, helping our neighbors heal and thrive.

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