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GI Associates
Release of Information (ROI) to
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) to GI Associates Form

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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 TO GI ASSOCIATES

Date*

MM slash DD slash YYYY

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)

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

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GI Associates?

Why choose GI Associates?

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GI Associates Release of Information (ROI) to 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) to GI Associates Form

GI Associates
Release of Information (ROI) to
GI Associates

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