ROI Form

Name

First NameLast Name
Relationship to Client*
Client's Date of Birth*

MonthDayYear
Date
Date*

MonthDayYear
Date
I understand that my health information may be protected by the Federal Rules for Privacy of Individually Identifiable Health Information (Title 45 of the Code of Federal Regulations, Parts 160 and 164, Title 42 of the Code of Federal Regulations, Chapter I, Part 2), and/or state laws. I understand that my health information may be subject to re-disclosure by the recipient and that if the organization or person authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by the Federal privacy regulations.

I understand that my records may contain information regarding my mental health, substance use or dependency, or sexuality, and also may contain confidential HIV/AIDS – related information. I further understand that by signing below, I am authorizing the release or exchange of these records to the parties named below. I understand that this authorization is voluntary and that I may revoke this authorization at any time by notifying Metro Behavioral Health in writing, but if I do, it will not have any effect on any actions Metro Behavioral Health took before it received the revocation.
Exchange InformationReceive InformationDisclose Information
VerballyIn writingObtain records/information fromRelease records/information from:
Agency/Contact*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Fax*
Format: (000) 000-0000.
Mental Health status reportProgress Notes / Treatment PlanChemical Dependency EvaluationSchool ReportsMedical Reports/Health HistoryFamily/Social HistoryCourt/CPS/Probation RecordsPsychological/Psychiatric EvaluationsVerification of Program EngagementAll of the aboveSummary of presenting problem(s), diagnostic findings, treatment, and clinical impressionsOther
I understand that this authorization will expire on: Date (MM/DD/YYYY) or if left blank, within on year of the date that this form is signed.
Signature*

Clear
DateTime*
Should be Empty: