Careers 715.847.2558 My GI Chart

Pay Online

Telehealth Appointments

715.847.2558 Careers My GI Chart

Pay Online

About Us Locations Prepare For Your Visit Telehealth Appointments

GI Associates
Release of Information (ROI)
From GI Associates

GI Associates offers the area’s
most advanced gastroenterology care.
Our physicians are experienced and our Adult Gastroenterologists are Board Certified.

GI Associates

Release of Information (ROI) from GI Associates Form

"*" indicates required fields

Step 1 of 2

50%

Name*

First Middle Last

Previous Name/Nicknames

Date of Birth*

MM slash DD slash YYYY

Address*

Street Address City State ZIP Code

Authorization*

I AUTHORIZE THE FOLLOWING ORGANIZATION TO DISCLOSE MY PHI FROM GI ASSOCIATES TO:

Date*

MM slash DD slash YYYY

Name of Person/Organization*

Phone #*

Fax #*

Address*

Street Address City State ZIP Code

Type of Information to be Released:

GI Associates Records (Information dictated/ordered by GastroIntestinal Associates providers only)

Office Visits

Procedure/PathPROCEDURE/PATH

Radiology Report

Lab Results

Growth Chart

Other

If checked, please specify:

Purpose or need for disclosure:

Further medical treatment

Other

Patient Use

If checked, please specify:

Information may be released electronically: (Please check which apply)

Email Address

Flash drive (this method is not encrypted)

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Why choose
GI Associates?

Why choose GI Associates?

Careers Locations Contact My GI Portal

Prepare for
your visit

Prepare for your visit

Services Conditions Disclosures Associate Portal

Request Appointment

715.847.2558

Open toolbar

Accessibility Tools

Increase Text
Decrease Text
Grayscale
High Contrast
Negative Contrast
Light Background
Links Underline
Readable Font
Reset

GI Associates Release of Information (ROI)From GI Associates

GI Associates offers the area’s most advanced gastroenterology care. Our physicians are experienced and our Adult Gastroenterologists are Board Certified.

GI Associates

Release of Information (ROI) from GI Associates Form

GI Associates
Release of Information (ROI)
From GI Associates

GI Associates offers the area’s
most advanced gastroenterology care.
Our physicians are experienced and our Adult Gastroenterologists are Board Certified.