ROI Forms

ROI Forms



ROI Forms

Part 1

A release of information form should contain the patient’s identification, which is the name and date of birth. It should have the name of the person or any other entity to which the information s released. The form should describe the health information that has already been authorized. It should contain the reason for the disclosure. It should include the condition on which such authorization will expire. This includes information such as the date or event of the expiration. This information is not present if the authorization is revoked at an earlier date. The form should contain the information showing that the patient or his or her legal representative can revoke any authorization given. It should contain the patient’s signature or that of his legal representative if he has one. It should contain a signature date indicating the day when the information was released.

Link to form:

The form has a section on the patient’s details. This includes the patient family name, first name, date of birth and address. It has a section where the person can indicate any other given names as well as the names of his parents. The other section contains information showing that the patient or his parent has given authorization for the information to be released. The form contains the name of the establishment that the patient is authorizing and the information that should be transmitted. It contains the address of the entity or person to receive the information, and a section of the patient’s signature and the signature of a witness.

Part 2

Link to agreement:

The agreement contains the name of the hospital and the title of the agreement at the top. At the end of the agreement, it has a section containing space for the signature, date, name of the person and his or her id, department, and position. In addition, it contains a section on the supervisor signature and the date signed. The agreement has certain provisions, which the employee has to read and agree before signing. The employee agrees to keep all the information received in any form confidentially during and after employment. The agreement contains provisions detailing that the patient understands the right of the hospital to conduct investigations on any unauthorized usage of data. The employee agrees not to use any data or information for any other purpose other than the recognized and authorized reasons.

Confidentiality agreements are important and a necessary requirement for healthcare professionals. Details such as the patient’s name, date of birth, address, age, and sex should be kept confidential. Any information on the contact details of the parents or guardians, medical history, bank details, progress reports, assessments, and personal correspondence are also kept confidential. Hospitals understand the importance of keeping the information they receive private as failure to do so can lead to legal suits. Every health care worker has to sign a confidential agreement. This is in recognition that every patient is entitled to privacy (Weil, 2007). However, information is often shared between two or more healthcare workers in the course of a patient’s treatment as this will improve the patient’s outcome.


Duffy, M., Dresser, S., & Fulton, J. (2009). Clinical nurse specialist toolkit: A guide for the new clinical nurse specialist. New York, NY: Springer Publishing Company

Wager, A. K., Lee, W. F., & Glaser, P. J. (2009). Health care information systems: A practical approach to health care management. Hoboken, NJ: John Wiley & Sons

Weil, A. D., & Regan, R. (2007). Independent medical coding: The comprehensive guidebook for career success as a medical coder. Windsor, CA: Rayve Productions

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