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WS Consent to Release Information (ROI) & Consent to Release Protected Health Information (PHI)
38
Questions
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HIPAA
Compliance
1
WS Form Completion Policy
*
This field is required.
WS will not accept form requests that are partially completed or deficient in the required information. Completing of forms that are forced to submit without the required elements will not be considered or attended to. The adult client and/or client's parent or guardian is responsible for the completion of all form data. It is not the responsibility of WS to complete form requests on behalf of the client and/or the client's parent or guardian. WS will not complete forms for an adult client and/or the client's parent or guardian.
YES
NO
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2
WS Verification of Identity Policy
*
This field is required.
If WS is not able to verify the identity of the individual submitting this request WS will not complete the request. Also, if WS requests additional information to complete this request and does not receive the requested information within 3 business days this request will expire. Please click YES below to indicate you understand and accept the WS policy acknowledgment. If you do not accept the WS policy information and acknowledgment then you may click NO; however, your request will not be accepted.
YES
NO
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3
WS Third Party Documentation & Communication Policy
*
This field is required.
WS will review and consider all requests to determine if the request is appropriate and valid to complete. WS does not acknowledge, respond to, or fulfill any documentation request or other communication requests from third parties, individuals, or companies/individuals who state they represent clients. WS does NOT accept subpoenas via email, fax, mail, or online forms. WS does not participate or cooperate in cases or instances where interaction with the legal system is requested or required. WS will not respond to phone calls, letters, emails, faxes, or online forms from anyone other than the client himself/herself or the client's parent or guardian. Please click YES below to indicate you understand and accept this WS policy acknowledgment. If you do not accept this WS policy acknowledgment then you may click NO; however, your request will not be accepted.
YES
NO
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4
WS Documentation & Communication Fees Policy
*
This field is required.
Please Be Aware That Some Forms of Documentation and Communication Requests Will Incur A Fee. The WS Fee Schedule is on the WS website. Submitting this request is both an acknowledgment of these fees and permission to accept fees associated with this request. WS will make every effort to attend to your request as soon as possible. Please be aware that WS will not accept a request for documentation and communication from anyone other than the client himself/herself or a client's parent or guardian. The WS estimated turnaround time for documentation and communication requests is approximately 7-10 business days. In the event, documentation and communication are needed sooner than 7-10 business days AND the WS staff are able to expedite a request additional fees will apply. WS will review and consider all requests to determine if the request is appropriate to complete. WS does NOT accept subpoenas via email, fax, mail, or online form. WS does not participate in cases or instances where interaction with the legal system is requested or required. Please click YES below to indicate you understand and accept the WS policy acknowledgment. If you do not accept the WS policy information and acknowledgment then you may click NO; however, your request will not be accepted
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NO
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5
Client is Currently...
*
This field is required.
Please choose the one option that best applies.
A Minor (Under the Age of 18)
An Adult (18+)
An Adult Under Guardianship
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6
Client First & Last Name
*
This field is required.
First Name
Last Name
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7
Client Initials
*
This field is required.
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8
Client Date of Birth
*
This field is required.
-
Date
Year
Month
Day
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9
Client Email
*
This field is required.
example@example.com
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10
Client Phone Number
*
This field is required.
Area Code
Phone Number
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11
Client Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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12
What is the First & Last Name of the Clinician Assigned to your Case?
*
This field is required.
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13
Client Verification of Identity
*
This field is required.
Take a picture of the client's current government issued photo identification. (If the client is a minor who does not have a government issued ID then please upload the parent or guardian's ID here and in the required upload to follow or you can also upload the client's school ID.)
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: 10.6MB
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14
Name of Parent or Guardian
First Name
Last Name
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15
Relationship to the Client of the Parent or Guardian
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16
Date of Birth of the Parent or Guardian
-
Date
Year
Month
Day
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17
Phone Number of the Parent or Guardian
Area Code
Phone Number
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18
Email of the Parent or Guardian
example@example.com
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19
Address of the Parent or Guardian
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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20
Verification of Identity of the Parent or Guardian
Take a picture of the parent's or guardian's current government issued photo identification. (Yes. We are aware that in some circumstances the same ID will be uploaded twice. This provision is to ensure WS receives the information required for proper HIPAA verification of identity.)
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21
Authorized Recipient Company or Organization Name
*
This field is required.
What is the name of the company or organization you want your information shared with? We must have specific information for the consent to release information (ROI) and the consent to release protected health information (PHI) to be valid.
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22
Authorized Recipient Address
*
This field is required.
What is the address of the company/organization who will be receiving your information? We must have specific information for the consent to release information and the consent to release protected health information (PHI) to be valid.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
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Libya
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Montenegro
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Morocco
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Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
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Nicaragua
Niger
Nigeria
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Portugal
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Rwanda
Saint Barthelemy
Saint Helena
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Samoa
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Saudi Arabia
Senegal
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23
Authorized Recipient Website
What is the website of the company/organization who is receiving your information. This information is used to ensure we send your information to the correct recipient to avoid errors.
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24
Authorized Recipient Representative's Name
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What is the full (first and last name) (spelled correctly) of the person at the company or organization you want your information shared with? We must have specific information for the consent to release information (ROI) and the consent to release protected health information (PHI) to be valid.
First Name
Last Name
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Authorized Recipient Title or Position
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What is the title or job position of the person at the company or organization receiving your information? We must have specific information for the consent to release information (ROI) and the consent to release protected health information (PHI) to be valid.
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Authorized Recipient's Relationship to the Client
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What is the relationship of the person receiving the information to the client? We must have specific information for the consent to release information (ROI) and the consent to release protected health information (PHI) to be valid.
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Authorized Recipient Phone Number
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What is the phone number of the person at the company or organization who will receive your information? We must have specific information for the consent to release information (ROI) and the consent to release protected health information (PHI) to be valid.
Area Code
Phone Number
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Authorized Recipient Fax Number
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What is the fax number of the person at the company or organization who will receive your information? We must have specific information for the consent to release information (ROI) and the consent to release protected health information (PHI) to be valid.
Area Code
Phone Number
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Authorized Recipient Email
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What is the email of the person at the company or organization who will be receiving your information? We must have specific information for the consent to release information (ROI) and the consent to release protected health information (PHI) to be valid.
example@example.com
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30
Contents of the Authorized Disclosure
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DO NOT LEAVE ANY OF THE OPTIONS BLANK. Wellness Solutions, LLC reserves the right to decline a consent that is not completed thoroughly or accurately.
Yes
No
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Demographics
Medications
Medical Concerns
Symptoms
Presenting Problems
Functional Impairments
Chemical Dependency & Substance Abuse
Trauma, Abuse, Neglect, & Exploitation
Intellectual & Developmental Functioning
Safety & Risk Information
Gender Identity & Sexual Orientation
Treatment Plan Objectives, Goals, Progress, & Information
Information Related to Medical Necessity
Counseling & Psychotherapy Clinical Documentation Including Assessments, Clinical Notes, Objective Measures, Non-Clinical Documentation, & Psychotherapy Notes
Information Regarding Billing, Payment, & Accounting
Information Regarding the Insurance Claims Submissions Process and Eligibility and Benefits Checks
Values, Beliefs, Spirituality, or Philosophy of Life
Cultural & Diversity Information
Discharge Planning & Discharge Plan
HIV and/or AIDS Status
Clinical Impressions
Information Related to Legal Concerns
Information Related to Social Service Involvement, Child Protective Services (CPS) Involvement, & Adult Protective Services (APS) Involvement
Information Related to Motivation, Compliance, & Participation
Other: (Please explain in the box below)
Demographics
Medications
Medical Concerns
Symptoms
Presenting Problems
Functional Impairments
Chemical Dependency & Substance Abuse
Trauma, Abuse, Neglect, & Exploitation
Intellectual & Developmental Functioning
Safety & Risk Information
Gender Identity & Sexual Orientation
Treatment Plan Objectives, Goals, Progress, & Information
Information Related to Medical Necessity
Counseling & Psychotherapy Clinical Documentation Including Assessments, Clinical Notes, Objective Measures, Non-Clinical Documentation, & Psychotherapy Notes
Information Regarding Billing, Payment, & Accounting
Information Regarding the Insurance Claims Submissions Process and Eligibility and Benefits Checks
Values, Beliefs, Spirituality, or Philosophy of Life
Cultural & Diversity Information
Discharge Planning & Discharge Plan
HIV and/or AIDS Status
Clinical Impressions
Information Related to Legal Concerns
Information Related to Social Service Involvement, Child Protective Services (CPS) Involvement, & Adult Protective Services (APS) Involvement
Information Related to Motivation, Compliance, & Participation
Other: (Please explain in the box below)
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Yes
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Yes
No
Yes
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Contents of the Authorized Disclosure - Additional Information
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Communication Channel Authorized for the Disclosure
*
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DO NOT LEAVE ANY OF THE OPTIONS BLANK. Wellness Solutions, LLC reserves the right to decline a consent that is not completed thoroughly or accurately filled.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Telephone / Voicemail / Text
Electronic Communication / Email
Mail
In-Person / Verbal
Fax
Writing (Paper or Electronic)
Other: (Please explain in the box below)
Telephone / Voicemail / Text
Electronic Communication / Email
Mail
In-Person / Verbal
Fax
Writing (Paper or Electronic)
Other: (Please explain in the box below)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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No
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Communication Channel Authorized for the Disclosure - Continued
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Purpose of the Authorized Disclosure
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DO NOT LEAVE ANY OF THE OPTIONS BLANK. Wellness Solutions, LLC reserves the right to decline a consent that is not completed thoroughly or accurately.
Yes
No
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No
Adult Protective Services (APS)
Child Protective Services (CPS)
Continuity of Care
Coordination of Care
Community Resource or Contact
Educational Involvement or Advocacy
Law Enforcement / Interactions with the Legal System
Referral
Social Security Advocacy
Support System Involvement
Other: (Please state in the box below)
Adult Protective Services (APS)
Child Protective Services (CPS)
Continuity of Care
Coordination of Care
Community Resource or Contact
Educational Involvement or Advocacy
Law Enforcement / Interactions with the Legal System
Referral
Social Security Advocacy
Support System Involvement
Other: (Please state in the box below)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Purpose of the Authorized Disclosure Continued:
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36
Authorized Disclosures - Click YES to Indicate Understanding & Acceptance for ALL Policy Disclosures. Click No to Indicate that You Do NOT Understand or Accept the Policy Disclosures. (If you choose NO for any of the Disclosure Policy Options Your Request Will Not Be Authenticated and the Request Will NOT Process.)
*
This field is required.
DO NOT LEAVE ANY OF THE OPTIONS BLANK. Wellness Solutions, LLC reserves the right to decline a consent that is not completed thoroughly or accurately.
Yes
No
Yes
No
Yes
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Yes
No
I understand that completion of this form gives Wellness Solutions, LLC permission to release confidential information, private information, protected health information (PHI), and information contained and pertaining to the client's healthcare record, counseling record, psychotherapy record, clinical information, clinical documentation, and additional highly sensitive information.
Wellness Solutions, LLC reserves the right to discriminate the disclosure of materials and information in the client’s chart even when provided with the permission to disclose information. I understand that Wellness Solutions, LLC is legally and ethically obligated to honor the minimal necessary rule with regards to authorized disclosures and that it is within the professional discretion of Wellness Solutions, LLC to make that determination.
The undersigned does hereby release, hold harmless and agree to indemnify Wellness Solutions, LLC, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring under this authorization.
I understand Wellness Solutions, LLC has a right to exercise discretion and discernment regarding authorized disclosures which includes the right to decline the release of information and/or to limit authorized disclosures.
I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by Federal or state law. I understand and accept that Wellness Solutions, LLC is not responsible for any subsequent, secondary, or accidental disclosures that may result directly and indirectly from this authorized disclosure.
I understand that this authorization remains effective until Wellness Solutions, LLC is in actual receipt of a signed revocation and/or until the records retention period required under federal and state law has expired. I understand that I have the right to revoke this authorization at any time, provided I do so in writing. WS will accept the signed revocation via email as long as the email contains an official government issued current picture identification that WS can verify and authenticate. The identification verification and revocation of authorization is required to be completed by the adult client or the minor client's parent or guardian.
I understand that I have the right to request a copy of the signed authorization. I am aware that Wellness Solutions, LLC e-sign documents are automatically courtesy copied to those signing said documents. Upon completion of this form you will receive a copy of this form via email and an email receipt to verify the submission of your request.
I understand that individuals other than the client who receive confidential information as a result this consent and disclosure are prohibited from redisclosure without specific consent from the client and/or the client's parent or guardian. Federal and state law protects the confidentiality of the information disclosed related to the individual’s alcohol and drug abuse treatment. Federal regulations (42 CFR Part 2) prohibit an individual from making any further disclosure 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 such regulations. Disclosure is limited to the purpose and persons included on the authorization form. Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. State laws may also protect the confidentiality of the client’s records.
For questions please contact Danielle C. Ellis, MA, MCJ, LPC, NCC and/or Wellness Solutions, LLC by calling (713) 893-3989 Monday – Friday 9 AM – 5 PM CST or emailing Admin@WellnessSolutionsLLC.COM . Wellness Solutions, LLC mailing address is 26310 Oak Ridge Drive, Suite 5, The Woodlands, Texas 77380.
I understand that completion of this form gives Wellness Solutions, LLC permission to release confidential information, private information, protected health information (PHI), and information contained and pertaining to the client's healthcare record, counseling record, psychotherapy record, clinical information, clinical documentation, and additional highly sensitive information.
Wellness Solutions, LLC reserves the right to discriminate the disclosure of materials and information in the client’s chart even when provided with the permission to disclose information. I understand that Wellness Solutions, LLC is legally and ethically obligated to honor the minimal necessary rule with regards to authorized disclosures and that it is within the professional discretion of Wellness Solutions, LLC to make that determination.
The undersigned does hereby release, hold harmless and agree to indemnify Wellness Solutions, LLC, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring under this authorization.
I understand Wellness Solutions, LLC has a right to exercise discretion and discernment regarding authorized disclosures which includes the right to decline the release of information and/or to limit authorized disclosures.
I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by Federal or state law. I understand and accept that Wellness Solutions, LLC is not responsible for any subsequent, secondary, or accidental disclosures that may result directly and indirectly from this authorized disclosure.
I understand that this authorization remains effective until Wellness Solutions, LLC is in actual receipt of a signed revocation and/or until the records retention period required under federal and state law has expired. I understand that I have the right to revoke this authorization at any time, provided I do so in writing. WS will accept the signed revocation via email as long as the email contains an official government issued current picture identification that WS can verify and authenticate. The identification verification and revocation of authorization is required to be completed by the adult client or the minor client's parent or guardian.
I understand that I have the right to request a copy of the signed authorization. I am aware that Wellness Solutions, LLC e-sign documents are automatically courtesy copied to those signing said documents. Upon completion of this form you will receive a copy of this form via email and an email receipt to verify the submission of your request.
I understand that individuals other than the client who receive confidential information as a result this consent and disclosure are prohibited from redisclosure without specific consent from the client and/or the client's parent or guardian. Federal and state law protects the confidentiality of the information disclosed related to the individual’s alcohol and drug abuse treatment. Federal regulations (42 CFR Part 2) prohibit an individual from making any further disclosure 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 such regulations. Disclosure is limited to the purpose and persons included on the authorization form. Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. State laws may also protect the confidentiality of the client’s records.
For questions please contact Danielle C. Ellis, MA, MCJ, LPC, NCC and/or Wellness Solutions, LLC by calling (713) 893-3989 Monday – Friday 9 AM – 5 PM CST or emailing Admin@WellnessSolutionsLLC.COM . Wellness Solutions, LLC mailing address is 26310 Oak Ridge Drive, Suite 5, The Woodlands, Texas 77380.
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37
Name of the Individual Completing This Form
*
This field is required.
First Name
Last Name
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38
I understand, accept, and provide consent for Wellness Solutions, LLC to release and/or share confidential, private, protected health information (PHI). I provide authorization for Wellness Solutions, LLC to release and/or share information. I have the legal authority to submit this request. By submitting this form I attest that I am the client or I am the client's parent (who has legal custody) or guardian. I understand that ONLY the client or the client's parent (who has legal custody) or guardian may authorize and consent to release confidential, private, protected health information and there are significant legal consequences for misrepresenting one's self. I authorize Wellness Solutions, LLC to charge the client's credit card on file for case management fees and/or any fees that may apply to the completion of this request.
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40
Timer
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41
Unique ID
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