ROI Request Generator
Generate a patient-authored Release of Information (ROI) request asking a covered entity to send a specified set of medical records to a named third-party recipient.
Open the generator → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Patient name
- Jane Doe
- DOB
- 1985-03-12
- From provider
- Acme Internal Medicine
- To recipient
- New Provider Internal Medicine
- Date range
- 2024-01-01 to 2025-01-01
- Records requested
- office notes, labs, imaging
- Delivery method
- secure email
Result: Click "Build printable ROI request" to render a release-of-information letter.
The tool opens with these values already filled in. Replace them with your own.
What you enter
Patient name and date of birth; the sending provider and the recipient; the date range and records requested; and the delivery method.
What this is
Generate a patient-authored Release of Information (ROI) request asking a covered entity to send a specified set of medical records to a named third-party recipient (another provider, the patient themselves, an attorney, an insurer, a family member). Sophie Well captures the patient and record-holder identifiers, the specific record set being requested (date range, encounter type, specialty), the recipient and delivery method (mailed paper, secure email, fax, patient portal), an expiration date, and the patient signature line, then returns a copy-paste-or-print document.
When to use it
Use this when a patient needs records moved between two providers or sent to a non-clinical recipient and the holder is dragging or asking what they need on paper. HIPAA's individual right of access (45 CFR 164.524) gives the patient the right to obtain their own records within 30 days and is the regulatory hammer if a request stalls; most providers also have their own preferred ROI form, and many will accept this letter as a complete request or as the cover letter to their form. For records sent directly to the patient, the right-of-access pathway has stronger protections than the third-party-disclosure pathway, so when the patient is the destination, say so explicitly.
How this is calculated
Patient-authorized release of records. Many providers require their own ROI form; this template can be attached or used as the basis.
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.