ROI

I, the undersigned, hereby authorize OhioGuidestone and its subsidiary organizations, collectively "The Agency", to use or disclose my personal health information and/or confidential information as described below to:

A date range for the time period to be released should be completed when records are requested or when only limited information is to be released. If no dates are entered, no time frame limitation will be applied

I understand and acknowledge that the requested information may contain information regarding physical and mental illness, HIV test results or diagnosis, AIDS or AIDS related conditions, alcohol and/or drug dependence/abuse*. I also understand that information used or disclosed according to this authorization may be subject to re-disclosure by the recipient and may no longer be protected. I understand that I may see and copy the information described on this form if requested in writing. I also understand that the provider may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. The health care providers listed above will not receive financial or in-kind compensation in exchange for using or disclosing my health care information. I understand I have a right to revoke this authorization (in writing) at any time. I understand that the revocation will not apply to information that has already been released in response to this authorization. If not revoked, this authorization will expire one year from the date written below or on the following date, event or condition (if earlier):

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.

**If you are signing the form on behalf of someone else and you are not the client's parent or guardian, you must provide the Agency with legal paperwork verifying your status as the client's personal representative. Acceptable forms of documentation include but are not limited to court order appointing guardian, durable power of attorney, and grandparent power of attorney. To upload this paperwork, please find the "Document Upload" section on this form and upload the required documents.

You have the right to revoke this release of information at any time. To do so, please contact your OhioGuidestone provider.

By clicking the "Submit" button, you agree to use electronic records and signatures. At any time, you may request a paper copy of any record provided or made available electronically to you by us. You will have the ability to receive email copies of documents you have submitted by entering your email address during the document submission process. If you do not have an email address, PRINT A COPY OF THIS RECORD prior to submission. If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can deliver services to you and complete certain steps in transactions with you. Further, you would no longer be able to use the OhioGuidestone Website eSignature System to receive required notices and consents electronically from us or to electronically sign documents from us. This consent to use of electronic records and signatures will apply to this and future records sent electronically to you by us. You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies, and to withdraw your prior consent to receive notices and disclosures electronically by sending an email to Compliance@OhioGuidestone.org.

The minimum system requirements for using the OhioGuidestone Website eSignature System may change over time. By clicking “Submit,” you agree that until or unless you notify us as described above, you consent to receive exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of your relationship with OhioGuidestone.