Release of Information (ROI)

Client Full Name*

Client DOB*

Date

Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Home Phone

Area CodePhone Number

Client Cell Phone

Area CodePhone Number

Client Email*

example@example.com

PROTECTED HEALTH INFORMATION (PHI) TO BE OBTAINED OR DISLCOSED TO:

Name of Individual or Organization*

Name of Provider

Title

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Fax Number*

Area CodePhone Number

I give permission for the following information to be shared:

I, the undersigned, hereby authorize a representative of Mindfully to use and/or disclose information from medical or financial record as specified above.

I understand and acknowledge that this authorization extends to all or any part of the records designated above, which may include documentation of treatment for mental health disorders, alcohol/drug abuse or dependence, and/or HIV/AIDs test results or diagnosis. I explicitly consent to the release of information as designated about. Furthermore, I consent to the release of the facsimile transmission of my protected health information as necessary.

This authorization may be revoked at any time to the extent that use and/or disclosure has not already occurred prior to your request for revocation. In order to revoke the authorization the individual/parent/legal guardian must submit a revocation request in writing to the disclosure. I also understand that Mindfully may charge a reasonable fee for the preparation, copying and postage as allowed by state law for copies of medical records.

I understand that Mindfully will not condition treatment, payment, enrollment or eligibility for benefits on the execution of this authorization. If the person/entity that received the above PHI is not a health care provider/health plan covered by federal privacy regulations, the PHI described above may be re-disclosed by such person/entity and will likely no longer be protected by the federal privacy regulations.

I understand that if I am requesting my physical records to be released to myself or another person/organization, I will need to complete an additional form titled Records Release Form.

This authorization will remain effective for one (1) year unless an earlier date or condition is specified here.

Is someone other than the client filling out this form?

No, I am the clientYes

Name of person completing form:

First NameLast Name

Relationship to Client

Drivers License

Browse Files

for verification purposes

Date*

Date

Signature*

Authorization of the Release of Protected Health Information