Authorization for Release and Exchange of Health Information (ROI)

Authorization for Release and Exchange of Health Information (ROI)

A Healing Place, Complete Counseling Care
Client Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Client Address*

Street Address

Street Address Line 2

CityState

Zip Code
Authorizes: A Healing Place, Complete Counseling Care, 325 N. Commercial St, Neenah WI 54956 to release protected health information to and receive from:
Name - Information May Be Released To/Received from:*

PrefixFirst NameLast NameSuffix
Organization
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number *

Area CodePhone Number
Fax Number

Area CodePhone Number
I authorize the above-named agencies/individuals to communicate and exchange written and/or verbal information regarding treatment. I release the above-named agencies/individuals from all legal responsibility that may arise from this act. A uniform charge for reproduction will be assessed.
Date of Service from:*

MonthDayYear
Date
Date of Service to: *

MonthDayYear
Date
Protected Health Information*

DiagnosisDischarge reportGuardianship RecordsIntake/Initial AssessmentTest resultsProgress NotesPsychiatric Records/NotesMedical recordsPsychological EvaluationsTreatment/care planSubstance Abuse Assessment and DiagnosisSubstance Abuse Discharge SummarySubstance Abuse Progress NotesSubstance Abuse TreatmentDiscuss case specificsCheck on Appointments
Non-Protected Health Information

Academic RecordsPupil Services RecordsLaw Enforcement RecordsCourt RecordsOther
In compliance with Wisconsin Statutes, which require special permission to release otherwise privileged information, please release records pertaining to:*

Mental HealthAlcoholismDevelopmental DisabilitiesDrug AbuseOther
Purpose of Disclosure (check all that apply)*

Further Medical CareInsurance Eligibility/BenefitsDevelopmental DisabilitiesDrug/Alcohol AbuseOther
I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans or health care clearinghouse who must follow the federal privacy standards, the health information disclosed because of this authorization may no longer be protected by the federal privacy standards and my health information may be disclosed without obtaining my authorization.

Your Rights with Respect to this Authorization

Right to Inspect or Copy the Health Information to be Use or Disclosed. I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contact A Healing Place, Complete Counseling Care, 325 N. Commercial St, Neenah, WI 54956

Right to Receive a Copy of this Authorization. I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form.

Right to Refuse to Sign this Authorization. I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above, whom I am authorizing to use and/or disclose my information, may not condition treatment, payment enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization.

Right to Withdraw this Authorization. I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawal, I may contact A Healing Place, Complete Counseling Care at 325 N. Commercial Street, Neenah WI 54956. I am aware that my withdrawal will not affect the use and/or disclosures of my health information that the person(s) and/or organization(s) listed above have already made based upon this authorization.

Disclosure of Direct or Indirect Payment Received by Any Person or Organization Authorized to Use or Disclose my Health Information. I understand that A Healing Place, Complete Counseling Care will not be receiving any direct or indirect payment in connection with the use or disclosure of my health information.
Unless revoked, this authorization is good until the the expiration time indicated below:

MonthDayYear
Date
Or until the following event(s):
Note to the Patient and Receiving Agency: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CRF Part 2). The Federal rule prohibits you from making any further disclosures of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CRF Part 2. A general authorization or release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.
By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement.
Client's Name
Patient Signature (14 years & older)

Clear
Date

MonthDayYear
Date
If signed by person other than the client, state relationship and authority to do so:

First NameLast Name
Legal Authority:

Custodial ParentLegal GuardianExecutor of Estate of DeceasedAuthorized Legal RepresentativePower of Attorney for Health Care
Client is :

MinorIncompetentDisabledDeceased
A PHOTOCOPY OF THIS RELEASE IS AS VALID AS THE ORIGINAL
Should be Empty: