ROI Form

Release of Information form

Lumiere Healing Centers 7593 Tylers Place Avenue West Chester, OH 45069
Patient Information(Required)
Authorization to Disclose Information(Required)

Recipient of Disclosure:

Name(Required)
Address(Required)
Information to be Disclosed:(Required)
Purpose of Disclosure:(Required)
The purpose of this disclosure is (check all that apply):

Expiration Date

This authorization will expire one year from the date of signature if no date is specified.

Revocation

I understand that I have the right to revoke this authorization at any time by submitting a written request to Lumiere Healing Centers. However, the revocation will not apply to information that has already been disclosed in reliance on this authorization.

Patient Signature

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my providing this authorization. I have read and understand the terms of this authorization.
Name(Required)
Max. file size: 256 MB.
Please upload an image of your photo ID
"This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see 42 CFR 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at 42 CFR 2.12(c)(5) and 42 CFR 2.65."

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