ROI - Evergreen General Release of Information

Evergreen Youth & Family Services

Authorization to Receive or Disclose Confidential Information
I understand that records are protected under the law and may not be disclosed without written permission as provided by the law. Note: A separate authorization is needed for each individual and/or agency
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I authorize Evergreen Youth & Family Services to:*

Receive InformationDisclose Information
Please enter below information regarding the individual or agency you are allowing Evergreen Youth & Family Services to share information with.
Individual or Agency:*
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number

Area CodePhone Number
This information is for (specify purpose):
This Information shall be limited to (check all that apply):*

Family/Social HistoryPsychological/PsychiatricEvaluations/ReportsEmployment RecordsMedical RecordsAssessment/TreatmentTreatment SummaryChemical DependencyEducational RecordsDiagnostic AssessmentOther
I understand that I do not have to sign this authorization and that refusal will not affect my ability to receive services.

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken/ or received has been disclosed prior to my written revocation.

I also understand that once Evergreen Youth & Family Services Inc., has disclosed information I have authorized, Evergreen Youth & Family Services Inc., no longer has control over the information and the information might be re-disclosed by the person/agency authorized to receive this information.
This authorization automatically expires one year from the date of the signing or under the following conditions (specify):
Signature of Client*

Clear
Parent/Guardian if client is a minor

First NameLast Name
Signature of parent/guardian

Clear
Should be Empty:

Evergreen Youth & Family Services